The Sixth Judicial District SBIRT
Three Question Screening Form

First Name:    

Last Name:    

Date of Birth:

Read questions as written. Record answers carefully. Begin the Screening by saying,

"Now I am going to ask you some questions about your use of alcoholic beverages during this past year"

Explain what is meant by "alcoholic beverages" by using local examples of beer, wine, vodka, etc. Code answers in terms of "standard drinks".  The answer number values will automatic code by the form.

  1. How often do you have a drink containing alcohol?
    (0) Never
    (1) Monthly or less
    (2) 2 to 4 times a month
    (3) 2 to 3 times a week
    (4) 4 or more times a week
  2. How many drinks containing alcohol do you have on a typical day when you are drinking?
    (0) 1 or 2
    (1) 3 or 4
    (2) 5 or 6
    (3) 7 to 9
    (4) 10 or more
  3. How often do you have five or more drinks on one occasion?
    (0) Never
    (1) Less than monthly
    (2) Monthly
    (3) Weekly
    (4) Daily or almost daily
  4. Current Score: 0

        ≥ 3       ≥ 4
    Women     Men

      =  Positive

    If positive, go to AUDIT, you have at least RISKY alcohol use.