[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Behavioral science](https://durgical.com/en/behavioral-science/) › [Psychological testing](https://durgical.com/en/behavioral-science/areas/testing/) › Screening questionnaires in primary care # Screening questionnaires in primary care - Test Short questionnaires help find people who may have depression, anxiety, risky drinking, memory problems or autism, so they can be evaluated properly. Updated Nov 5, 2026 ## Key points - PHQ-9: depression, 0–27; cutoffs 5, 10, 15 and 20 mark mild, moderate, moderately severe and severe; 10 or more is a common positive screen. - Any positive answer on the PHQ-9 item about thoughts of death or self-harm needs a same-visit suicide risk assessment, whatever the total. - GAD-7: anxiety, 0–21; 5, 10 and 15 mark mild, moderate and severe; 10 or more warrants evaluation. - AUDIT (WHO, 10 items, 0–40): 8 or more suggests hazardous or harmful drinking; AUDIT-C uses the three consumption items. - CAGE (4 yes or no questions): 2 or more suggests a drinking problem, but it misses risky drinking without consequences. - M-CHAT-R/F: autism screening by parents at 16–30 months; universal autism screening at 18 and 24 months. ## What it is Screening questionnaires are brief, validated tools that flag people at higher probability of a condition among those without a known diagnosis. They favor sensitivity, so a positive result means ‘evaluate further’, never ‘diagnosis made’. Each has its own target, age group and cutoffs, and some also grade severity and are used to follow treatment. The items of these tools are not reproduced here; clinicians use the official validated versions, including Spanish versions. ## Key facts - PHQ-2 (the first two PHQ-9 items) is an ultra-brief first step; 3 or more leads to the full PHQ-9. - AUDIT risk zones: 0–7 lower risk, 8–15 hazardous use, 16–19 harmful use, 20 or more possible dependence. - AUDIT-C (0–12) is often considered positive at 4 or more in men and 3 or more in women; cutoffs vary by country and version. - Brief cognitive screening tests (about ten minutes, scored out of 30) detect possible cognitive impairment; scores are influenced by education and language. - EPDS (Edinburgh Postnatal Depression Scale, 10 items, 0–30) screens for depression in pregnancy and after birth and includes anxiety and self-harm items. - M-CHAT-R/F risk bands: 0–2 low, 3–7 medium (follow-up interview), 8–20 high (refer for diagnostic evaluation and early intervention). ## Common screening tools: target and what the score means | Tool | Screens for | Who and when | Score meaning | | --- | --- | --- | --- | | [PHQ-9](https://durgical.com/en/conditions/major-depressive-disorder/) | Depression and its severity | Adolescents and adults | 0–27; 10 or more positive; also used to follow response | | [GAD-7](https://durgical.com/en/conditions/generalized-anxiety-disorder/) | Generalized anxiety (also flags panic, social anxiety, PTSD) | Adults | 0–21; 10 or more positive | | [AUDIT](https://durgical.com/en/conditions/alcohol-use-disorder/) | Hazardous and harmful drinking, possible dependence | Adults | 0–40; 8 or more positive; zones guide the intervention | | [AUDIT-C](https://durgical.com/en/conditions/alcohol-use-disorder/) | Risky drinking (consumption only) | Adults, quick screen | 0–12; positive about 4 or more in men, 3 or more in women | | [CAGE](https://durgical.com/en/conditions/alcohol-use-disorder/) | Established alcohol problems | Adults | 0–4; 2 or more clinically significant; low sensitivity for risky use | | [Brief cognitive screening tests](https://durgical.com/en/conditions/dementia/) | Cognitive impairment, possible dementia | Older adults with memory concerns | Usually out of 30; lower scores suggest impairment; adjust for education | | [EPDS](https://durgical.com/en/conditions/perinatal-depression-and-postpartum-psychosis/) | Perinatal depression | Pregnancy and the first year after birth | 0–30; cutoffs about 10–13 vary by setting; self-harm item reviewed always | | [M-CHAT-R/F](https://durgical.com/en/conditions/autism-spectrum-disorder/) | Autism spectrum disorder risk | Toddlers 16–30 months, parent answers | 0–2 low, 3–7 medium, 8–20 high risk | ## Clinical notes - The NIAAA advises against CAGE for screening because it detects only people already harmed by drinking; AUDIT-C or a single heavy-drinking-day question is preferred. - Screening only helps when a pathway exists for positives: evaluation, brief intervention, treatment or referral. ## In the lab - Validated Spanish versions exist for these tools; using unofficial translations changes their accuracy. - Screening is followed by a diagnostic interview; the questionnaire does not replace it. ## Memory aid The number in the name tells the length: PHQ-9 nine questions, GAD-7 seven, AUDIT-C three of the ten. ## Test yourself Think of the answer, then tap the question to see it. ## What PHQ-9 total score is commonly used as a positive screen for depression? 10 or more, which corresponds to at least moderate depressive symptoms. ## A patient scores 6 on the PHQ-9 but marks thoughts of self-harm. What is the next step? Assess suicide risk at the same visit, regardless of the low total score. ## Why is CAGE a weak screen for risky drinking? It asks about consequences of drinking, so it misses people who drink heavily but have no problems yet. ## At what ages is universal autism screening recommended? At the 18-month and 24-month well-child visits. ## What does the EPDS screen for? Depression during pregnancy and after birth (perinatal depression). [Add to my cards (5)](https://durgical.app/estudiar/?add=/en/behavioral-science/screening-questionnaires-in-primary-care/) ## Elsewhere in DurgiPedia - [Mental status: orientation, attention and screening tests](https://durgical.com/en/clinical-exam/mental-status-orientation-attention-and-screening-tests/) - [Medicines, allergies and habits: tobacco, alcohol and other substances](https://durgical.com/en/clinical-exam/medicines-allergies-and-habits-tobacco-alcohol-and-other-substances/) - [Comprehensive geriatric assessment: function, cognition, falls](https://durgical.com/en/clinical-exam/comprehensive-geriatric-assessment-function-cognition-falls/) ## Connections ## Related 4 - [Psychological testing: reliability, validity and norms](https://durgical.com/en/behavioral-science/psychological-testing-reliability-validity-and-norms/) - [Screening and brief intervention (SBIRT) and harm reduction](https://durgical.com/en/behavioral-science/screening-and-brief-intervention-and-harm-reduction/) - [Developmental milestones: domains, corrected age and red flags](https://durgical.com/en/behavioral-science/developmental-milestones-domains-corrected-age-and-red-flags/) - [Normal psychological ageing vs dementia](https://durgical.com/en/behavioral-science/normal-psychological-ageing-vs-dementia/) ## Related conditions 8 - [Major depressive disorder](https://durgical.com/en/conditions/major-depressive-disorder/) - [Generalized anxiety disorder](https://durgical.com/en/conditions/generalized-anxiety-disorder/) - [Alcohol use disorder](https://durgical.com/en/conditions/alcohol-use-disorder/) - [Dementia (major neurocognitive disorder)](https://durgical.com/en/conditions/dementia/) - [Mild cognitive impairment](https://durgical.com/en/conditions/mild-cognitive-impairment/) - [Perinatal depression and postpartum psychosis](https://durgical.com/en/conditions/perinatal-depression-and-postpartum-psychosis/) - [Autism spectrum disorder (ASD)](https://durgical.com/en/conditions/autism-spectrum-disorder/) - [Suicidal behaviour and suicide risk](https://durgical.com/en/conditions/suicidal-behaviour-and-suicide-risk/) [← All of behavioral science](https://durgical.com/en/behavioral-science/) Educational content on behavior and the clinical relationship; not a diagnostic or treatment guide and no substitute for assessment by a health professional. If you or someone near you is at risk, seek help now from an emergency service or a mental-health helpline. Sources: [Screen and Assess: Use Quick, Effective Methods](https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/screen-and-assess-use-quick-effective-methods) (National Institute on Alcohol Abuse and Alcoholism (NIAAA), 2025); [AUDIT: the Alcohol Use Disorders Identification Test: guidelines for use in primary health care](https://www.who.int/publications/i/item/WHO-MSD-MSB-01.6a) (World Health Organization, 2001); [Clinical Screening for Autism Spectrum Disorder](https://www.cdc.gov/autism/hcp/diagnosis/screening.html) (Centers for Disease Control and Prevention (CDC), 2025). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/behavioral-science/screening-questionnaires-in-primary-care/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/behavioral-science/screening-questionnaires-in-primary-care/