CIWA-Ar: Clinician-administered every 4–8 hours during alcohol withdrawal. Guides benzodiazepine dosing. Intermediate scores (non-anchor points) are valid — use clinical judgement to interpolate.
Nausea / Vomiting (0–7)
Ask: "Do you feel sick to your stomach? Have you vomited?" Observe.
Tremor (0–7)
Arms extended, fingers spread. Observe.
Paroxysmal Sweats (0–7)
Observe.
Anxiety (0–7)
Ask: "Do you feel nervous?" Observe.
Agitation (0–7)
Observe.
Tactile Disturbances (0–7)
Ask: "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?"
Auditory Disturbances (0–7)
Ask: "Are you more aware of sounds around you? Are they harsh? Do you hear anything that is disturbing to you? Are you hearing things you know are not there?"
Visual Disturbances (0–7)
Ask: "Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?"
Headache / Fullness in Head (0–7)
Ask: "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness.
