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Substance Use Screening (CAGE-AID)
Screening

Substance Use Screening (CAGE-AID)

2 pages•12 fields•HIPAA-ready
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Substance Use Screening (CAGE-AID)
Patient Information
Have you felt you should cut down?
Have people annoyed you about your use?
Have you felt guilty about your use?
Have you used first thing in the morning?
Alcohol Use Frequency
Select...
Drug Use Frequency
Select...
Tobacco/Nicotine Use
Select...
Impact on Daily Life
Readiness for Change
Confidentiality Acknowledgment
Submit
Use this template

The Substance Use Screening form provides a structured approach to screening for alcohol and drug use disorders based on the CAGE-AID (Cut down, Annoyed, Guilty, Eye-opener -- Adapted to Include Drugs) framework. This validated screening tool helps identify patients who may benefit from further evaluation or treatment for substance use disorders.

Beyond the core CAGE-AID questions, this template includes frequency and quantity assessment for common substance categories (alcohol, tobacco, cannabis, prescription misuse, and illicit drugs), impact evaluation on work, relationships, and health, and a readiness-for-change assessment. The frequency questions use standardized intervals that align with AUDIT-C and NIDA screening recommendations.

The form is designed with sensitivity, using non-judgmental language and optional response fields where appropriate. Confidentiality assurances are prominent, noting that substance use information receives additional federal protections under 42 CFR Part 2. This template is used in primary care annual screenings, behavioral health intakes, emergency department SBIRT (Screening, Brief Intervention, Referral to Treatment) programs, and pre-surgical assessments.

What's included

  • CAGE-AID validated screening questions
  • Substance frequency and quantity assessment
  • Impact evaluation on work, health, relationships
  • Readiness-for-change assessment
  • 42 CFR Part 2 confidentiality acknowledgment
  • Referral and resource documentation

Who uses this template

  • Primary care annual substance use screening
  • Behavioral health and addiction intake
  • Emergency department SBIRT programs
  • Pre-surgical substance use assessment

All form fields

11 fields across 2 pages. Customize any field after signing up.

Patient InformationText
Have you felt you should cut down?Multiple Choice
Have people annoyed you about your use?Multiple Choice
Have you felt guilty about your use?Multiple Choice
Have you used first thing in the morning?Multiple Choice
Alcohol Use FrequencyDropdown
Drug Use FrequencyDropdown
Tobacco/Nicotine UseDropdown
Impact on Daily LifeCheckbox
Readiness for ChangeMultiple Choice
Confidentiality AcknowledgmentCheckbox

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