Member Name: __________ UCare ID #: ________ Date:



Member Name: FORMTEXT ?????UCare ID #: FORMTEXT ????? PMI#: FORMTEXT ?????Date: FORMTEXT ?????Care Coordinator Name: FORMTEXT ????? FORMCHECKBOX UCare FORMCHECKBOX Other Partner: FORMTEXT ?????CAGE Questionnaire Please check the answers to the following 4 YES or NO questions:1. Have you ever felt you should Cut down on your drinking? Check Answer: FORMCHECKBOX YES or FORMCHECKBOX NO2. Have people Annoyed you by criticizing your drinking?Check Answer: FORMCHECKBOX YES or FORMCHECKBOX NO3. Have you ever felt bad or Guilty about your drinking?Check Answer: FORMCHECKBOX YES or FORMCHECKBOX NO4. Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?Check Answer: FORMCHECKBOX YES or FORMCHECKBOX NO ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download