Clinical institute withdrawal assessment scale for alcohol, revised (CIWA-Ar)

Scoring
Total score is a simple sum of each score item (maximum is 67) <10: Very mild withdrawal 10-15: Mild withdrawal 16-20: Modest withdrawal >20: Severe withdrawal

Nausea and vomiting
0 No nausea and vomiting 1 2 3 4 Intermittent nausea with dry heaves 5 6 7 Constant nausea, frequent dry heaves and vomiting

Paroxysmal sweats
0 No sweats visible 1 Barely visible sweating, palms moist 2 3 4 Beads of sweat obvious on forehead 5 6 7 Drenching sweats

Anxiety
0 No anxiety 1 2 3 4 Moderately anxious, guarded 5 6 7 Acute panic state, consistent with severe delirium or acute schizophrenia

Agitation
0 Normal activity 1 Somewhat more than normal activity 2 3 4 Moderately fidgety and restless 5 6 7 Paces back and forth during most of the interview or constantly thrashes about

Tremor
0 No tremor 1 Not visible, but can be felt at fingertips 2 3 4 Moderate when patient's hands extended 5 6 7 Severe, even with arms not extended

Headache
0 Not present 1 Very mild 2 Mild 3 Moderate 4 Moderately severe 5 Severe 6 Very severe 7 Extremely severe

Auditory disturbances
0 Not present 1 Very mild harshness or ability to frighten 2 Mild harshness or ability to frighten 3 Moderate harshness or ability to frighten 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations

Visual disturbances
0 Not present 1 Very mild photosensitivity 2 Mild photosensitivity 3 Moderate photosensitivity 4 Moderately severe visual hallucinations 5 Severe visual hallucinations 6 Extremely severe visual hallucinations 7 Continuous visual hallucinations

Tactile disturbances
0 None 1 Very mild paresthesias 2 Mild paresthesias 3 Moderate paresthesias 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations

Orientation and clouding of sensorium
0 Orientated and can do serial additions 1 Cannot do serial additions 2 Disoriented for date by no more than 2 calendar days 3 Disoriented for date by more than 2 calendar days 4 Disoriented for place and/or patient