Addiction Research Foundation Clinical Institute Withdrawal Assessment - Alcohol (CIWA-Ar)
|Patient: _____________||Date: (yy/mm/dd) ____/____/____||Time: (24 hr) _________|
|Pulse or heart rate: ___________||Blood Pressure: ______________|
and Vomiting - Ask "Do you feel sick to your stomach?" "Have
you vomited?" Observation.
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? Observation.
- Arms extended and fingers spread apart. Observation.
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 that you know aren't there?" Observation.
Sweats - Observation.
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 you? Are you
seeing things that you know aren't there?" Observation.
- Ask "Do you feel nervous?" Observation.
Fullness in Head - Ask "Does your head feel different? Does it feel like
there is a band around your head?" Do not rate dizziness or lightheadedness.
Otherwise, rate severity.
and Clouding of Sensorium - Ask "What day is this? Where are you? Who am I?
Total CIWA-A Score _____
Rater's Initials _____
Maximum Possible Score - 67
This scale is not copyrighted and may be used freely