Alcohol/Substance Abuse

Explains task, assures confidentiality, obtains consent

 * Hello my name is [Medical Student] and I'm a first year medical student at [Medical School].
 * Can I get your full name and age please?
 * Mr. Doe, today my attending physician has asked me to take your history.
 * This will require me asking a few questions about your health, do I have your permission?
 * I just want to remind you that anything we discuss will be confidential.
 * Is there anything you need before we begin?

Begins with open ended questions and transitions

 * What brings you in today?

Establishes alcohol intake: amount, type, duration

 * How much alcohol do you drink per week?
 * What kind of alcohol do you drink?
 * How long have you been drinking?
 * Mr. Doe, I want to ask you a few questions about your drinking habits, is that okay with you?

Screens for abuse using CAGE questions

 * Have you ever felt you needed to cut down on your drinking?
 * Have people annoyed you by criticizing your drinking?
 * Have you ever felt guilty about drinking?
 * Have you ever felt you needed a drink first thing in the morning to steady your nerves or to get rid of a hangover?
 * Mr. Doe, I'm asking to ask you a few more personal questions about your drinking so I can get a better picture of what's going on; is that okay?

Screens for addiction i.e. asks about negative consequences such as health issues, loss of work, DUI, relationship issues etc.

 * Have you ever had any health related issues due to drinking?
 * Have you ever had any problems with work due to drinking?
 * Have you ever had a DUI?
 * Have you had any relationship issues due to drinking?

Asks about depression

 * Is there anything in your life that you're depressed about?
 * Is there anything in your life that's causing you stress?

Asks about illicit/recreational drug use

 * Do you take any other recreational drug such as cocaine or marijuana?

Asks about family history of alcohol abuse

 * Is there anyone in your family that have trouble with alcohol?
 * Thank you for your honesty Mr. Doe.

Demonstrates empathy, offers counselling -- help available

 * Mr. Doe, I'm sorry you haven't been feeling well but I think you'll feel better sooner if you stop drinking.
 * Have you ever ever thought about quitting alcohol?
 * I just want to let you know that we have counselling and resources to help you quit alcohol whenever you're ready.
 * That's all for your history, thank you for coming in.
 * Do you have any questions?

Summary presentation and communication skills

 * Example
 * We have a 50 year african male that has signs of jaundice.
 * The patient has been drinking 3 glasses of Vodka a day for the past 2 years and has positive CAGE test.
 * The patient continues to drink despite negative consequences such as DUIs.
 * He has a family history of alcohol abuse.