DE-ADDICTION & COUNSELLING CENTER CARMELARAM P.O.,BANGALORE - 560 035
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)
Pulse or heart rate, taken for one minute:_________________________ Blood pressure:______
NAUSEA AND VOMITING -- Ask "Do you feel sick to your TACTILE DISTURBANCES -- Ask "Have you any itching, pins and stomach? Have you vomited?" Observation. needles sensations, any burning, any numbness, or do you feel bugs 0 no nausea and no vomiting crawling on or under your skin?" Observation. 1 mild nausea with no vomiting 0 none 2 1 very mild itching, pins and needles, burning or numbness 3 2 mild itching, pins and needles, burning or numbness 4 intermittent nausea with dry heaves 3 moderate itching, pins and needles, burning or numbness 5 4 moderately severe hallucinations 6 5 severe hallucinations 7 constant nausea, frequent dry heaves and vomiting 6 extremely severe hallucinations 7 continuous hallucinations
TREMOR -- Arms extended and fingers spread apart. AUDITORY DISTURBANCES -- Ask "Are you more aware of Observation. sounds around you? Are they harsh? Do they frighten you? Are you 0 no tremor hearing anything that is disturbing to you? Are you hearing things you 1 not visible, but can be felt fingertip to fingertip know are not there?" Observation. 2 0 not present 3 1 very mild harshness or ability to frighten 4 moderate, with patient's arms extended 2 mild harshness or ability to frighten 5 3 moderate harshness or ability to frighten 6 4 moderately severe hallucinations 7 severe, even with arms not extended 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations
PAROXYSMAL SWEATS -- Observation. VISUAL DISTURBANCES -- Ask "Does the light appear to be too 0 no sweat visible bright? Is its color different? Does it hurt your eyes? Are you seeing 1 barely perceptible sweating, palms moist anything that is disturbing to you? Are you seeing things you know are 2 not there?" Observation. 3 0 not present 4 beads of sweat obvious on forehead 1 very mild sensitivity 5 2 mild sensitivity 6 3 moderate sensitivity 7 drenching sweats 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations
ANXIETY -- Ask "Do you feel nervous?" Observation. HEADACHE, FULLNESS IN HEAD -- Ask "Does your head feel 0 no anxiety, at ease different? Does it feel like there is a band around your head?" Do not 1 mild anxious rate for dizziness or lightheadedness. Otherwise, rate severity. 2 0 not present 3 1 very mild 4 moderately anxious, or guarded, so anxiety is inferred 2 mild 5 3 moderate 6 4 moderately severe 7 equivalent to acute panic states as seen in severe delirium or 5 severe acute schizophrenic reactions 6 very severe 7 extremely severe AGITATION -- Observation. ORIENTATION AND CLOUDING OF SENSORIUM -- Ask 0 normal activity "What day is this? Where are you? Who am I?" 1 somewhat more than normal activity 0 oriented and can do serial additions 2 1 cannot do serial additions or is uncertain about date 3 2 disoriented for date by no more than 2 calendar days 4 moderately fidgety and restless 3 disoriented for date by more than 2 calendar days 5 4 disoriented for place/or person 6 7 paces back and forth during most of the interview, or constantly thrashes about Total CIWA-Ar Score ______ Maximum Possible Score 67
For the Councillor:
Scoring the CIWA-AR:
Nine items scored on a scale ranging from 0 (no symptoms) to 7 (most severe symptoms) One item scored on a scale ranging from 0 (no symptoms) to 4 (disoriented with respect to place or person)
Interpretation
Total Score less than 8 : Mild Withdrawal
Total Score between 8 and 15 : Moderate Withdrawal Total Score greater than 15 : Sever Withdrawal
