TITLE: PREVALENCE OF ALCOHOL DEPENDENCE AMONG OUT-PATIENTS
IN A TERTIARY CARE HOSPITAL
Informed consent:
Date:
I, _______________________, ____ years, have been informed about the study titled
“Prevalence of alcohol dependence among out-patients in a tertiary care hospital” and the
process involves my own language. I am aware that the personal details I disclose will be
kept confidential and have been assured that my privacy will be maintained. Adequate
opportunities have been provided to clear my doubts. I am also aware that my participation is
voluntary. I may withdraw at any time during the course of the study. I give my consent to
use my data for academic purposes only.
Participant name& signature
QUESTIONNAIRE:
Demographic data:
Name:
Age:
Residence:
Occupation:
CAGE QUESTIONNAIRE:
1. Have you ever felt you should Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt bad or Guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a
hangover (Eye opener)?
The Alcohol Use Disorders Identification Test: Interview Version
Read questions as written. Record answers carefully. Begin the AUDIT 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”.
Place the correct answer number in the box at the right.
1. How often do you have a drink containing 6. How often during the last year have you needed a
alco- hol? first drink in the morning to get yourself going after
a heavy drinking session?
(0) Never [Skip to Qs 9-10]
(1) Monthly or less (0) Never
(2) 2 to 4 times a month (1) Less than monthly
(3) 2 to 3 times a week (2) Monthly
(4) 4 or more times a week (3) Weekly
(4) Daily or almost daily
2. How many drinks containing alcohol do you 7. How often during the last year have you had a
have on a typical day when you are drinking? feeling of guilt or remorse after drinking?
(0) 1 or 2 (0) Never
(1) 3 or 4 (1) Less than monthly
(2) 5 or 6 (2) Monthly
(3) 7, 8, or 9 (3) Weekly
(4) 10 or more (4) Daily or almost daily
3. How often do you have six or more drinks on 8. How often during the last year have you been
one occasion? unable to remember what happened the night
before because you had been drinking?
(0) Never
(1) Less than monthly (0) Never
(2) Monthly (1) Less than monthly
(3) Weekly (2) Monthly
(4) Daily or almost daily (3) Weekly
Skip to Questions 9 and 10 if Total Score for (4) Daily or almost daily
Questions 2 and 3 = 0
4. How often during the last year have you found 9. Have you or someone else been injured as a
that you were not able to stop drinking once result of your drinking?
you had started? (0) No
(0) Never (2) Yes, but not in the last year
(1) Less than monthly (4) Yes, during the last year
(2) Monthly
(3) Weekly
(4) Daily or almost daily
5. How often during the last year have you failed 10. Has a relative or friend or a doctor or another health
to do what was normally expected from you worker been concerned about your drink- ing or
because of drinking? suggested you cut down?
(0) Never (0) No
(1) Less than monthly (2) Yes, but not in the last year
(2) Monthly (4) Yes, during the last year
(3) Weekly
(4) Daily or almost daily
Record total of specific items here
If total is greater than recommended cut-off, consult User’s Manual.
