====== Alcohol Withdrawal Scale ======

==== Temperature (per axilla) ====

|1|37.0-37.5 C|
|2|37.6-38 C|
|3|greater than 38.0C|

==== Pulse (beats per minute) ====

|1|90-95|
|2|96-100|
|3|101-105|
|4|106-110|
|5|111-120|
|6|greater than120|

==== Respiration rate (inspirations per minute) ====

|1|20-24|
|2|greater than 24|

==== Blood pressure (diastolic in mmHg) ====

|1|95-100|
|2|101-103|
|3|104-106|
|4|107-109|
|5|110-112|
|6|greater than 112|

==== Nausea and vomiting ("Do you feel sick? Have you vomited?") ====

|0|None|
|1|Nausea with no vomiting|
|4|Intermittent nausea with dry heaves|
|6|Nausea, dry heaves, vomiting|

==== Tremor (arms extended, fingers spread) ====

|0|No tremor|
|2|Not visible- can be fet fingertip to fingertip|
|4|Moderate with arms extended|
|6|Severe even with arms not extended|

==== Sweating (observation) ====

|0|No sweat visible|
|2|Barely perceptible, palms moist|
|4|Beads of sweat visible|
|6|Drenching sweats|

==== Tactile disturbances (Do you feel any itching, pins and needles or numbness?) ====

|0|None|
|2|Mild itching or pins and needles or numbness|
|4|Intermittent tactile hallucinations (e.g. bugs crawling)|
|6|Continuous tactile hallucinations|

==== Auditory disturbances (loud noises, hearing voices) ====

|0|Not present|
|2|Mild harshness or ability to frighten (increased sensitivity)|
|4|Intermittent auditory hallucinations (appears to hear things you cannot)|
|6|Continuous auditory hallucinations (shouting talking to unseen persons)|

==== Visual disturbances (photophobia, seeing things) ====

|0|Not present|
|2|Mild sensitivity (bothered by lights)|
|4|Intermittent visual hallucinations (occasionally sees things you cannot)|
|6|Continuous visual hallucinations (seesing things constantly)|

==== Clouding of sensorium ("what day is this? What is this place?") ====

|0|Orientated|
|2|Disorientated for date by no more than 2days|
|4|Disorientated for date|
|6|Disorientated by place (re-oriente if necessary)|

==== Quality of contact ====

|0|In contact with examiner|
|2|Seems in contact but is oblivious to environment|
|4|Periodically becomes detached|
|6|Makes no contact with the examiner|

==== Anxiety (Do you feel nervous?) ====

|0|No anxiety; at ease|
|2|Appears anxious|
|4|Moderately anxious or guarded|
|6|Overt anxiety (equal to panic)|

==== Agitation (your observation) ====

|0|Normal activity|
|2|Somewhat more than normal activity|
|4|Moderately fidgety and restless|
|6|Pacing or thrashing about constantly|

==== Thought disturbances (flight of ideas) ====

|0|No disturbance|
|2|Does not have much control over the nature of thoughts|
|4|Plagued by unpleasant thoughts constantly|
|6|Thoughts come quickly and in a disconnected fashion|

==== Convulsions (seizures or fits of any kind) ====

|0|No|
|6|Yes|

==== Headache ====

|0|Not present|
|2|Mild|
|4|Moderately severe|
|6|Severe|

==== Flushing of face ====

|0|None|
|1|Mild|
|2|Severe|

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