Full Name Age Mobile No NAUSEA AND VOMITING - Select -No nausea and no vomiting (0)Mild nausea with no vomiting (1)Mild nausea (2)Moderate nausea (3)Intermittent nausea with dry heaves (4)Frequent nausea (5)Severe nausea (6)Constant nausea, frequent dry heaves, and vomiting (7) TREMOR - Select -No tremor (0)Not visible, but can be felt (1)Mild tremor (2)Moderate tremor (3)Moderate, arms extended (4)Marked tremor (5)Severe tremor (6)Severe, even with arms not extended (7) PAROXYSMAL SWEATS - Select -No sweat visible (0)Barely perceptible sweating (1)Mild sweating (2)Moderate sweating (3)Beads of sweat obvious (4)Heavy sweating (5)Very heavy sweating (6)Drenching sweats (7) ANXIETY - Select -No anxiety (0)Mild anxiety (1)Moderate anxiety (2)Marked anxiety (3)Moderately severe anxiety (4)Severe anxiety (5)Very severe anxiety (6)Acute panic states (7) AGITATION - Select -Normal activity (0)Slight restlessness (1)Mild agitation (2)Moderate agitation (3)Moderately fidgety (4)Restless (5)Very restless (6)Constant thrashing (7) TACTILE DISTURBANCES - Select -None (0)Very mild sensations (1)Mild sensations (2)Moderate sensations (3)Moderately severe hallucinations (4)Severe hallucinations (5)Extremely severe hallucinations (6)Continuous hallucinations (7) AUDITORY DISTURBANCES - Select -Not present (0)Very mild disturbance (1)Mild disturbance (2)Moderate disturbance (3)Moderately severe hallucinations (4)Severe hallucinations (5)Extremely severe hallucinations (6)Continuous hallucinations (7) VISUAL DISTURBANCES - Select -Not present (0)Very mild sensitivity (1)Mild sensitivity (2)Moderate sensitivity (3)Moderately severe hallucinations (4)Severe hallucinations (5)Extremely severe hallucinations (6)Continuous hallucinations (7) HEADACHE, FULLNESS IN HEAD - Select -Not present (0)Very mild (1)Mild (2)Moderate (3)Moderately severe (4)Severe (5)Very severe (6)Extremely severe (7) ORIENTATION AND CLOUDING OF SENSORIUM - Select -Oriented (0)Uncertain about date (1)Disoriented by ≤2 days (2)Disoriented by >2 days (3)Disoriented for place/person (4) CIWA-Ar Result Total CIWA-Ar Score: 0 Severity: Minimal withdrawal
