Alcohol Withdrawal Assessment Scale, CIWA-AR Test - the question form
Questions: 10 · 2 minutes
1. Nausea and vomiting
0: No nausea and no vomiting
1: Mild nausea with no vomiting
2
3
4: Intermittent nausea and dry heaves
5
6
7: Constant nausea, frequent dry heaves, and vomiting
2. Tremor. Arms extended and fingers spread apart. Observe.
0: No tremor
1: Tremor not visible, but can be felt fingertip to fingertip
2
3
4: Moderate tremor with arms extended
5
6
7: Severe tremor even with arms not extended
3. 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: Profuse sweating
4. Anxiety ("Do you feel nervous?") Observation.
0: No anxiety; patient feels at ease
1: Mild anxiety
2
3
4: Moderate anxiety or guardedness, so anxiety is reduced
5
6
7: Equivalent to acute panic states seen in severe delirium or acute schizophrenic reactions
5. Agitation (observation).
0: Normal activity
1: Activity is slightly more than normal
2
3
4: Moderately fidgety and restless
5
6
7: Paces back and forth constantly during the interview, or is thrashing about
6. Tactile disturbances: Do you have any itching, pins and needles, burning, numbness, or the feeling of bugs crawling on or under your skin? (Observation.)
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: Moderate hallucinations
5: Severe hallucinations
6: Extremely severe hallucinations
7: Continuous hallucinations
7. Auditory disturbances
0: None
1: Very mild harshness or ability to startle
2: Mild harshness or ability to startle
3: Moderate harshness or ability to startle
4: Moderately severe hallucinations
5: Severe hallucinations
6: Extremely severe hallucinations
7: Continuous hallucinations
8. Visual disturbances (observation): Does the light seem too bright? Is it a different color than usual? Does it hurt your eyes? Are you seeing anything that is disturbing you? Are you seeing things 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 hallucinations
7: Continuous hallucinations
9. Headache; feeling of pressure in the head
0: Not present
1: Very mild
2: Mild
3: Moderate
4: Moderately severe
5: Severe
6: Very severe
7: Extremely severe
10. Orientation and perceptual disturbances. Ask: “What day is it today? Where are you? Who am I?” Ask the patient to count backward from 10 by 3.
0: Patient is oriented and can perform serial additions
1: Patient cannot perform serial additions or is uncertain about the date
2: Patient is incorrect about the date, but by no more than 2 calendar days
3: Patient is incorrect about the date by more than 2 calendar days
4: Patient is incorrect about place and/or person (examiner)