About this template
The Alcohol Use Disorders Identification Test (AUDIT) is a validated screening tool developed by the World Health Organization (WHO) to identify individuals whose alcohol consumption may be hazardous or harmful to their health. This digital Google Form template enables healthcare providers, counselors, and wellness centers to streamline patient intake and preliminary health evaluations. By allowing patients to complete the questionnaire privately and securely before their appointment, clinics can foster more open, honest clinical conversations and reduce in-office wait times.
This comprehensive assessment collects data across ten standardized domains covering drinking frequency, typical consumption volumes, dependence symptoms, and alcohol-related harm. Using Doc2Form, healthcare teams can instantly deploy this template, customize the questions to match specific clinical protocols, and aggregate patient responses securely for clinical review.
Designed with patient comfort in mind, the form guides respondents through clear, structured prompts while maintaining professional medical standards. Whether utilized in primary care, behavioral health practices, or wellness programs, this template simplifies clinical workflows and ensures accurate documentation for every patient encounter.
Key features
- Standardized WHO AUDIT questions for reliable clinical screening
- Streamlined digital intake that reduces in-office paperwork
- Customizable fields to integrate seamlessly into your existing practice workflow
- Mobile-friendly format for convenient patient completion on any device
- Automatic response organization via Google Sheets for effortless tracking
Use cases
Routine primary care patient health screenings and annual wellness vi…
Routine primary care patient health screenings and annual wellness visits
Initial intake evaluations for behavioral health and counseling clinics
Substance use awareness programs and workplace wellness check-ins
Pre-treatment assessments for rehabilitation and recovery centers
What this form collects
- Patient Identifier or Initials (Short answer)Enter your patient ID, case number, or initials for our records.
- Assessment Date (Date)Select today's date.
- How often do you have a drink containing alcohol? (Multiple choice)Consider any drink containing beer, wine, liquor, or malt beverages.
- How many standard drinks containing alcohol do you have on a typical day when you are drinking? (Multiple choice)A standard drink is roughly one 12oz beer, one 5oz glass of wine, or 1.5oz of distilled spirits.
- How often do you have six or more drinks on one occasion? (Multiple choice)Refers to heavy episodic drinking sessions.
- How often during the last year have you found that you were not able to stop drinking once you had started? (Multiple choice)Select the frequency that best applies to your experience over the past 12 months.
- How often during the last year have you failed to do what was normally expected of you because of drinking? (Multiple choice)For example, missing work, school, or failing to meet family obligations.
- How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? (Multiple choice)Consider instances where you felt hungover or experienced withdrawal symptoms.
- How often during the last year have you had a feeling of guilt or remorse after drinking? (Multiple choice)Refers to emotional distress caused by your drinking behavior.
- How often during the last year have you been unable to remember what happened the night before because you had been drinking? (Multiple choice)Includes memory blackouts or missing time spans.
- Have you or someone else been injured as a result of your drinking? (Multiple choice)Consider physical injuries sustained by yourself or others due to alcohol consumption.
- Has a relative, friend, doctor, or other healthcare worker been concerned about your drinking or suggested you cut down? (Multiple choice)Refers to feedback or concern expressed by people close to you or medical professionals.
- Additional Notes or Comments (Paragraph)Please share any additional context or information you would like your healthcare provider to know.
FAQ
What is the AUDIT questionnaire?
The AUDIT (Alcohol Use Disorders Identification Test) is a 10-question screening tool developed by the World Health Organization to assess alcohol consumption, drinking behaviors, and potential alcohol-related problems.
Can I customize the questions on this Google Form template?
Yes. Once you generate the form using Doc2Form, you have full control over the Google Form editor to add clinic-specific instructions, adjust branding, or modify questions as needed.
Is patient health information secure on Google Forms?
Google Forms provides robust encryption in transit and at rest. However, depending on your jurisdiction, you should ensure your Google Workspace account meets relevant healthcare data privacy standards (such as HIPAA) before collecting sensitive patient information.
How are the test scores calculated?
While standard Google Forms does not automatically calculate complex clinical scores on the submission page, all patient answers are logged directly into a linked Google Sheet where you can easily apply formulas to compute total AUDIT scores.
How do I share this form with my patients?
You can share the form via a direct link, embed it on your practice website, or send it via email as part of your pre-appointment onboarding workflow.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.