NAUSEA AND VOMITING--
Ask "Do you feel sick to your stomach? Have you vomited? "
Observation.
0 no nausea and no vomiting
1 mild nausea with no vomiting
2
3
4 intermittent nausea with dry heaves
5
6
7 constant nausea, frequent dry heaves and vomiting
TACTICLE 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.
0 none
1 mild itching, pins and needles, burning or numbness
2 mild itching, pins and needles, burning or numbness
3 moderate itching, pins and needles, burning or numbness
4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations
TREMOR--Arms extended and fingers spread apart.
Observation.
0 no tremor
1 not visible, but can be felt fingertip to fingertip
2
3
4 moderate, with patient's arms extended
5
6
7 severe, even with arms not extended
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?"
Observation.
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.
PAROSYSMAL SWEATS--Observation.
0 no sweat visible
1 barely perceptible sweating, palms moist
2
3
4 beads of sweat obvious on forehead
5
6
7 drenching sweats
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?"
Observation.
0 not present
1 very mild sensitivity
2 mild sensitivity
3 moderate sensitivity
4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations
ANXIETY--Ask "Do you feel nervous?"
Observation.
0 no anxiety, at ease
1 mildly anxious
2
3
4 moderately anxious, or guarded, so anxiety is inferred
5
6
7 equivalent to acute panic states as seen in severe delirium or acute
schizophrenic reactions.
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.
0 not present
1 very mild
2 mild
3 moderate
4 moderately severe
5 severe
6 very severe
7 extremely severe
AGITATION--Observation.
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
ORIENTATION AND CLOUDING OF SENSORIUM--Ask "What day is
this? Where are you? Who am I?"
0 oriented and can do serial additions
1 cannot do serial additions or is uncertain about date
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 person
Total CIWA-A Score ____
Rater's Initials ____
Maximum Possible Score 67
* Usual hypnotic dose
** Phenobarbital withdrawal conversion equivalence is not the same as
therapeutic dose equivalency. Withdrawal equivalence is the amount of
the drug that 30 mg of phenobarbital will substitute for and prevent
serious high-dose withdrawal signs and symptoms.
Information in this exhibit is drawn from two sources, the American
Psychiatric Association and the work of Donald R. Wesson, et al.
Portions of the exhibit are reprinted with permission from the
American Psychiatric Press Textbook of Substance Abuse Treatment,
Washington, D.C. 1990.
* Butalbital is usually available in combination
with opiate or non-opiate analgesics.
** Phenobarbital withdrawal conversion equivalence is not the same as
therapeutic dose equivalency. Withdrawal
equivalence is the amount of the drug that 30 mg of phenobarbital will
substitute for and prevent serious high-dose
withdrawal signs and symptoms.
Information in this exhibit is drawn from two sources, the American
Psychiatric Association and the work of Donald R. Wesson, et al.
Portions of the exhibit are reprinted with permission from the
American Psychiatric Press Textbook of Substance Abuse Treatment,
Washington, D.C., 1990.
I understand that my records are protected under the Federal regulations
governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42
C.F.R. Part 2, and cannot be disclosed without my written consent unless
otherwise provided for in the regulations. I also understand that I may
revoke this consent at any time except to the extent that action has
been taken in reliance on it, and that in any event this consent expires
automatically as follows:
_________________________________________________________________________
_______
(Specification of the date, event, or condition upon which this consent
expires)
Dated: _________________________________________________________________
(Signature of participant)
_________________________________________
(Signature of parent, guardian, or
authorized representative when required
Prohibition on Redisclosing Information Concerning AOD Abuse Treatment
Patients
This notice accompanies a disclosure of information concerning a client
in alcohol/drug abuse treatment, made to you with the consent of such
client. This information has been disclosed to you from records
protected by Federal confidentiality rules (42 C.F.R. Part 2). The
Federal rules prohibit you from making any further disclosure of this
information unless further disclosure is expressly permitted by the
written consent of the person to whom it pertains or as otherwise
permitted by 42 CFR Part 2. A general authorization for the release of
medical or other information is NOT sufficient for this purpose. The
Federal rules restrict any use of the information to criminally
investigate or prosecute any alcohol or drug abuse patient.
1. Acknowledges that in receiving, storing, processing, or otherwise
dealing with any information from the Program about the patients in the
Program, it is fully bound by the provisions of the Federal Regulations
governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42
CFR Part 2; and
2. Undertakes to resist in judicial proceedings any effort to obtain
access to information pertaining to patients otherwise than as expressly
provided for in the Federal confidentiality regulations, 42 CFR Part
2.
Executed this _____ day of __________, 199__.
_________________________ _________________________
President Program Director
XYZ Service Center (Name of Program)
(Address) (Address)
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