BSN Tracker

Assessment Tool: CAGE Questionnaire

The CAGE questionnaire is a validated four-item screen for alcohol use disorder. Each item targets a key behavioural indicator — attempted cutting down, criticism from others, guilt feelings, and morning drinking (eye-opener). A score of ≥ 2 identifies patients who warrant more comprehensive evaluation. CAGE is used as an initial screen in health history encounters; a positive result should be followed by the full AUDIT and clinical assessment, not treated as diagnostic in isolation.

CAGE Questionnaire

A four-item yes/no screen for alcohol use disorder. Each "Yes" answer scores 1 point. A score of ≥ 2 is considered clinically significant and warrants further evaluation. Originally validated in primary care and inpatient settings; widely used as a brief initial screen before more comprehensive instruments such as the AUDIT.

Score interpretation

0

No significant concern

1

Low concern — monitor

≥ 2

Positive screen — further assessment indicated

CAGE is a screening tool only. A positive screen does not diagnose alcohol use disorder; it indicates the need for a comprehensive clinical assessment.

C — Have you ever felt you should Cut down on your drinking?
A — Have people Annoyed you by criticising your drinking?
G — Have you ever felt bad or Guilty about your drinking?
E — Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?