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 |