5Shot Alcohol Screening Tool 5Shot Your Name * Date of Birth * Your GP/Nurse * Please choose from the list Dr Cash Dr Walls Dr Boyd Dr Calvert Dr MacSorley Dr Carswell Dr Duffy Dr Dickie Dr Mayson Dr Dickson Dr Woin ANP Claire Hill Nurse Angela MacArthur Nurse Pauline Tang Nurse Shona Swain Nurse Siobhan Badger How often do you have a drink containing alcohol? * (0.0) Never (0.5) Monthly or less (1.0) Two to four times a month (1.5) Two to three times a week (2.0) Four or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking? * (0.0) 1 or 2 (0.5) 3 or 4 (1.0) 5 or 6 (1.5) 7 to 9 (2.0) 10 or more Have people annoyed you by criticising your drinking? * (0.0) No (1.0) Yes Have you ever felt bad or guilty about your drinking? * (0.0) No (1.0) Yes Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang-over? * (0.0) No (1.0) Yes Scoring Score of 2.5 or greater indicates possible alcohol misuse and the need for further investigation Maximum Score = 7 reCAPTCHA If you are human, leave this field blank. Submit Start Over
