| RPT |
.| .| Clinical Institute Withdrawal Assessment - Alcohol Revised| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN:
to you? Are you seeing things you know are not there?" Observation: | <*Answer_7321*>| 12. 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:| <*Answer_7323*>| 13. ORIENTATION AND CLOUDING OF SENSORIUM - Ask, "What day is this? Where are you? Who
am I?"| <*Answer_7325*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be
verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~
<.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | CIWA-AR| Total Score: <-Total Score->| | Scores of less than 8 indicate mild withdrawal, 8-15
indicate moderate| withdrawal (marked autonomic arousal) and >15 indicate severe withdrawal| and are also predictive of the development of seizures and delirium.| | Questions and Answers| | 1.
Time (use 24 hour clock, midnight is 00:00):| <*Answer_7313*>| 2. Pulse or heart rate (taken for one minute):| <*Answer_7314*>| 3. Blood pressure:| <*Answer_7315*>| 4. NAUSEA AND VOMITING
- Ask, "Do you feel sick to your stomach? Have you vomited?" Observation:| <*Answer_7316*>| 5. TREMOR - Arms extended and fingers spread apart. Observation:| <*Answer_7318*>| 6. PAROXYSMAL
SWEATS - Observation:| <*Answer_7320*>| 7. ANXIETY - Ask, "Do you feel nervous?" Observation:| <*Answer_7322*>| 8. AGITATION - Observation:| <*Answer_7324*>| 9. 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?" Observation:| <*Answer_7317*>| 10. 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: | <*Answer_7319*>| 11. 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
|
