Nausea / Vomiting

0 — No nausea and no vomiting+01 — Mild nausea with no dry heaves+12 — Mild nausea+23 — Moderate nausea with some dry heaves+34 — Intermittent nausea with dry heaves+45 — Frequent nausea with dry heaves+56 — Frequent vomiting+67 — Constant nausea, frequent dry heaves and vomiting+7

Tremor (arms extended, fingers spread)

0 — No tremor+01 — Not visible, but felt fingertip to fingertip+12 — Barely visible tremor+23 — Mild visible tremor+34 — Moderate tremor with arms extended+45 — Moderate-to-severe tremor+56 — Severe tremor+67 — Severe tremor even with arms not extended+7

Paroxysmal Sweats

0 — No sweating visible+01 — Barely perceptible sweating, palms moist+12 — Mild sweating, palms and forehead moist+23 — Moderate sweating+34 — Beads of sweat obvious on forehead+45 — Profuse sweating, forehead and neck+56 — Very profuse sweating+67 — Drenching sweats+7

Anxiety

0 — No anxiety, at ease+01 — Mildly anxious+12 — Mild-to-moderate anxiety+23 — Moderate anxiety+34 — Moderately anxious, guarded (anxiety inferred)+45 — Significant anxiety+56 — Severe anxiety+67 — Equivalent to acute panic states+7

Agitation

0 — Normal activity+01 — Somewhat more than normal activity+12 — Mildly restless+23 — Moderately restless+34 — Moderately fidgety and restless+45 — Markedly fidgety and restless+56 — Unable to sit still most of the time+67 — Paces back and forth or constantly thrashes about+7

Tactile Disturbances

0 — None+01 — Very mild itching, pins and needles, burning, or numbness+12 — Mild itching, pins and needles, burning, or numbness+23 — Moderate itching, pins and needles, burning, or numbness+34 — Moderately severe tactile hallucinations+45 — Severe tactile hallucinations+56 — Extremely severe hallucinations+67 — Continuous tactile hallucinations+7

Auditory Disturbances

0 — Not present+01 — Very mild harshness or ability to frighten+12 — Mild harshness or ability to frighten+23 — Moderate harshness or ability to frighten+34 — Moderately severe auditory hallucinations+45 — Severe auditory hallucinations+56 — Extremely severe hallucinations+67 — Continuous auditory hallucinations+7

Visual Disturbances

0 — Not present+01 — Very mild light sensitivity+12 — Mild light sensitivity+23 — Moderate light sensitivity+34 — Moderately severe visual hallucinations+45 — Severe visual hallucinations+56 — Extremely severe hallucinations+67 — Continuous visual hallucinations+7

Headache / Fullness in Head

Orientation / Clouding of Sensorium

0 — Oriented; can do serial additions+01 — Cannot do serial additions or uncertain about date+12 — Date disorientation by ≤ 2 calendar days+23 — Date disorientation by > 2 calendar days+34 — Disoriented for place and/or person+4

CIWA-Ar: Alcohol Withdrawal Assessment

CIWA-Ar: Alcohol Withdrawal Assessment