Patient:

Date:

Time:

Heart rate:

Blood pressure:

Nausea and vomiting (observation)

0

None

1

Mild nausea and no vomiting

2

3

4

Intermittent nausea with dry heaves

5

6

7

Constant nausea, frequent dry heaves and vomiting

Tremor (observation; arms extended and fingers spread apart)

0

No tremor

1

Not visible but can be felt fingertip to fingertip

2

3

4

Moderate, with patient’s arms extended

5

6

7

Severe, even with arms not extended

Paroxysmal sweats (observation)

0

No sweat visible

1

Barely perceptible sweating, palms moist

2

3

4

Beads of sweat obvious on forehead

5

6

7

Drenching sweats

Anxiety (observation; ask the patient: “Do you feel nervous?”)

0

No anxiety, at ease

1

Mildly anxious

2

3

4

Moderately anxious, or guarded, so anxiety is inferred

5

6

7

Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

Agitation (observation)

0

Normal activity

1

Somewhat more than normal activity

2

3

4

Moderately fidgety and restless

5

6

7

Paces back and forth during most of the interview or constantly thrashes about

Tactile disturbances (observation; ask the patient: “Do you have any itching, pins and needles sensations, any burning, any numbness? Do you feel bugs crawling on or under your skin?”)

0

None

1

Very mild itching, pins and needles, burning, or numbness

2

Mild itching, pins and needles, burning, or numbness

3

Moderate itching, pins and needles, burning, or numbness

4

Moderately severe hallucinations

5

Severe hallucinations

6

Extremely severe hallucinations

7

Continuous hallucinations

Auditory disturbances (observation; ask the patient: “Are you more aware of sounds around you? Are they harsh? Do they frighten you? Do you hear anything that is disturbing you? Can you hear things you know are not there?”)

0

Not present

1

Very mild harshness or ability to frighten

2

Mild harshness or ability to frighten

3

Moderate harshness or ability to frighten

4

Moderately severe hallucinations

5

Severe hallucinations

6

Extremely severe hallucinations

7

Continuous hallucinations

Visual disturbances (observation; ask the patient: “Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Can you see anything that is disturbing to you? Are you seeing things that you know are not there?)

0

Not present

1

Very mild sensitivity

2

Mild sensitivity

3

Moderate sensitivity

4

Moderately severe hallucinations

5

Severe hallucinations

6

Extremely severe visual hallucinations

7

Continuous hallucinations

Headache, fullness in head (observation; ask the patient: “Does your head feel different? Does it feel like there is a band around your head?”; do not rate for dizziness or light-headedness; otherwise, rate severity)

0

Not present

1

Very mild

2

Mild

3

Moderate

4

Moderately severe

5

Severe

6

Very severe

7

Extremely severe

Orientation and clouding of sensorium (observation; ask the patient: “What day is this? Where are you? Who am I?”)

0

Oriented and can do serial additions

1

Cannot do serial additions or is uncertain about date

2

Disoriented for date by ≤2 calendar days

3

Disoriented for date by >2 calendar days

4

Disoriented for place and/or person

The maximum possible score is 67 points.

Total CIWA-Ar score:

Rater’s initials: