CIWA

1
Name* This field is required.
First Name
Last Name
2
Chart #* This field is required.
3
Nausea/ Vomiting* This field is required.0=none / 7=constant with frequent dry heaves
4
Tremors* This field is required.0=none / 7=severe
5
Anxiety* This field is required.0=none / 7=severe
6
Agitation* This field is required.0=none / 7=pacing back and forth
7
Paroxysmal Sweating* This field is required.0=no sweats / 7=drenching sweats
8
Tactile Disturbance* This field is required.0=none / 7=continuous hallucination
9
Auditory Disturbance* This field is required.0=none / 7=continuous hallucination
10
Visual Disturbance* This field is required.0=none / 7=continuous hallucination
11
Headache* This field is required.0=none / 7=severe
12
Orientation to Person, Place and Time* This field is required.0=none / 4=severe
13
Today's Provider* This field is required.
Please Select
Please Select
Guy M. Lerner, MD
Leslie Dally, DO
Don Zinno, APRN
Erika Ruth, MD
Craig Rouben, APRN
Tara O'Brien, APRN
Monica Taylor, APRN, PMHNP
Brandi Thomas, APRN, PMHNP
14
Score
15
Date
Date
Month
Day
Year
16
Type of screener
17
The CIWA Score is: {score}

If less than 8 = MINIMAL/ Mild alcohol withdrawal, drug therapy not necessarily indicated

If 8 -14= MODERATE/ Drug therapy indicated

If greater than 15 = SEVERE/ Consider in patient treatment
Should be Empty: