Name	Value
REPORT NUMBER	39
INSTRUMENT	COWS
RPT	.\| .\| Clinical Opiate Withdrawal Scale\| \| Date Given: <.Date_Given.>\| Clinician: <.Staff_Ordered_By.>\| Location: <.Location.>\| \| Veteran: <.Patient_Name_Last_First.>\| SSN: <.Patient_SSN.>\| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)\| Gender: <.Patient_Gender.>\| \| COWS Scale: <-COWS Scale->\| \| 5-12 Mild withdrawal\| 13-24 Moderate\| 25-36 Moderately severe\| 37+ Severe withdrawal\| \| Questions and Answers\| \| 1. Resting Pulse Rate: \| <Answer_4022>\| 2. Sweating: \| <Answer_4033>\| 3. Restlessness: \| <Answer_4035>\| 4. Pupil size:\| <Answer_4036>\| 5. Bone or joint aches:\| <Answer_4037>\| 6. Runny nose or tearing: \| <Answer_4038>\| 7. GI upset: \| <Answer_4039>\| 8. Tremor: \| <Answer_4040>\| 9. Yawning: \| <Answer_4041>\| 10. Anxiety or Irritability:\| <Answer_4042>\| 11. Gooseflesh skin:\| <Answer_4043>\| \| $~

Name

Value

REPORT NUMBER

INSTRUMENT

RPT

.| .| Clinical Opiate Withdrawal Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: 
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | COWS Scale: <-COWS Scale->| |         5-12      Mild withdrawal|         13-24     Moderate|         25-36     Moderately 
severe|         37+       Severe withdrawal| | Questions and Answers| | 1. Resting Pulse Rate: |     <*Answer_4022*>| 2. Sweating: |     <*Answer_4033*>| 3. Restlessness: |     <*Answer_4035*>| 4. 
Pupil size:|     <*Answer_4036*>| 5. Bone or joint aches:|     <*Answer_4037*>| 6. Runny nose or tearing: |     <*Answer_4038*>| 7. GI upset: |     <*Answer_4039*>| 8. Tremor: |     <*Answer_4040*>| 
9. Yawning: |     <*Answer_4041*>| 10. Anxiety or Irritability:|     <*Answer_4042*>| 11. Gooseflesh skin:|     <*Answer_4043*>|  |           $~

39 (39) MH REPORT (601.93)