CIWA-Ar Calculator

Nausea/vomiting (Ask ‘Do you feel sick to your stomach? Have you vomited?’)

No nausea and no vomiting

Mild nausea and no vomiting

(More severe symptoms)

Intermittent nausea with dry heaves

(More severe symptoms)

Constant nausea, frequent dry heaves and vomiting

Tremor (Arms extended and fingers spread apart)

No tremor

Not visible, but can be felt fingertip to fingertip

(More severe symptoms)

Moderate, with patient’s arms extended

(More severe symptoms)

Severe, even with arms not extended

Paroxysmal sweats

No sweat visible

Barely perceptible sweating, palms moist

(More severe symptoms)

Beads of sweat obvious on forehead

(More severe symptoms)

Drenching sweats

Anxiety (Ask, ‘Do you feel nervous?’)

No anxiety, at ease

Mildly anxious

(More severe symptoms)

Moderately anxious, or guarded, so anxiety is inferred

(More severe symptoms)

Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

Agitation

Normal activity

Somewhat more activity than normal activty

(More severe symptoms)

Moderately fidgety and restless

(More severe symptoms)

Paces back and forth during most of the interview, or constantly thrashes about

Tactile disturbances (Ask, ‘Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?’)

None

Very mild itching, pin and needles, burning, or numbness

Mild itching, pin and needles, burning, or numbness

Moderate itching, pin and needles, burning, or numbness

Moderately severe hallucinations

Severe hallucinations

Extremely severe hallucinations

Continuous hallucinations

Auditory disturbances (Ask, ‘Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?’)

Not present

Very mild harshness or ability to frighten

Mild harshness or ability to frighten

Moderate harshness or ability to frighten

Moderately severe hallucinations

Severe hallucinations

Extremely severe hallucinations

Continuous hallucinations

Visual disturbances (Ask ‘Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?’)

Headache/fullness in head (Ask ‘Does your head feel different? Does it feel like there is a band around your head?’ Do not rate for dizziness or lightheadedness. Otherwise, rate ‘severity.’)

Orientation/clouding of sensorium (Ask ‘What day is this? Where are you? Who am I?’)

Oriented, can do serial additions

Can’t do serial additions or is uncertain about date

Disoriented for date by no more than 2 calendar days

Disoriented for date by more than 2 calendar days

Disoriented to place or person

CIWA-Ar Score