Brief Negotiated Interview Checklist
INSTRUCTIONS: Please check either YES, NO, or N/A (not applicable), or score one number between 1 and 7, where
applicable, for each of the following items.
Did the Provider… YES NO N/A
1) Ask patient for permission to discuss alcohol use and pause for their
2) Review patient’s drinking patterns and express concern?
3) Ask patient if he/she sees a connection between drinking and health care
4) Make a specific connection between drinking and health care visit or other
medical issue (e.g., MVC, GI complaints, hypertension)?
5) Inform patient about the exact NIAAA guidelines relevant to his/her sex and
age group and tell patient his/her drinking is above guidelines and unsafe ?
6) Ask patient to select a number on the “Readiness Ruler”?
7) What was the number? (please write # in box)
8) Ask patient why he/she did not pick a lower number?
9) Ask patient: What would make his/her drinking a problem?
OR Ask how important would it be for the patient to prevent that from
OR Discuss patient’s pros and cons of drinking?
10) Tell patient in a confrontational manner, that they have to cut down?
11) Make suggestions regarding how much patient should cut down?
12) Refer to patient as an “alcoholic”
13) Negotiate a drinking goal with the patient based on what patient has said
by asking: What would you like to do?
14) Tell patient that if he/she can stay within NIAAA limits he/she will be less
likely to experience (further) illness or injury related to alcohol use?
15) Provide a drinking agreement sheet?
16) Add his/her advice on the agreement?
17) Provide written information?
18) Encourage patient to schedule a follow-up appointment?
19) Thank patient for his/her time?
20) Offer confrontational warnings regarding drinking?
21) To what degree does the provider reflect patient’s motivational statements
regarding cutting down? (please write # in box)
1 2 3 4 5 6 7
not at all somewhat extensively
22) Re-direct non-motivational statements? (please write # in box)
1 2 3 4 5 6 7
not at all somewhat extensively so