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