CAGE Substance Abuse Screening Tool

*** This form will be submitted electronically by standard email as a password-protected pdf file directly to the practice nurse. If you wish to send your name and date of birth in a de-identified manner please write a bogus name and advise reception by phone to link to your file. ***

Instruction

When you submit the questionnaire, you will see your score at the next screening with an explanation.

Score Guide
> 3 = suggests heavy alcohol use
Today's date*
Patient Name*
Patient DOB*
1. Have you ever felt you ought to cut down on your drinking or drug use?
- No (0 pt)
- Yes (1 pt)
2. Have people annoyed you by criticizing your drinking or drug use?
- No (0 pt)
- Yes (1 pt)
3. Have you felt bad or guilty about your drinking or drug use?
- No (0 pt)
- Yes (1 pt)
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?
- No (0 pt)
- Yes (1 pt)

CAGE Substance Abuse Screening Tool

Instruction

Select which type of appointments you wish to book