Nausea / Vomiting i Ask: "Do you feel sick to your stomach? Have you vomited?" Observe for signs of nausea. 0 - No nausea and no vomiting 1 - Mild nausea with no vomiting 2 - Mild nausea with no vomiting (intermittent) 3 - Nausea with occasional dry heaves 4 - Intermittent nausea with dry heaves 5 - Frequent nausea with dry heaves 6 - Constant nausea with frequent dry heaves 7 - Constant nausea, frequent dry heaves and vomiting
Tremor i Observe arms extended and fingers spread apart. Ask patient to hold arms out. 0 - No tremor 1 - Not visible but can be felt fingertip to fingertip 2 - Slight visible tremor 3 - Moderate tremor, visible with arms extended 4 - Moderate tremor with patient arms extended 5 - Prominent tremor with arms extended 6 - Severe tremor even with arms not extended 7 - Severe tremor even with arms not extended
Paroxysmal Sweats i Observe the patient for visible perspiration. 0 - No sweat visible 1 - Barely perceptible sweating, palms moist 2 - Mild sweating 3 - Moderate sweating 4 - Beads of sweat obvious on forehead 5 - Heavy sweating on forehead and face 6 - Profuse sweating 7 - Drenching sweats
Anxiety i Ask: "Do you feel nervous?" Observe for clinical signs of anxiety (agitation, tension). 0 - No anxiety, at ease 1 - Mildly anxious 2 - Mildly to moderately anxious 3 - Moderately anxious 4 - Moderately anxious, or guarded (anxiety inferred) 5 - Marked anxiety 6 - Near-panic level anxiety 7 - Equivalent to acute panic states as in severe delirium or schizophrenic reactions
Agitation i Observe patient behavior throughout the assessment. 0 - Normal activity 1 - Somewhat more than normal activity 2 - Mildly fidgety 3 - Moderately fidgety 4 - Moderately fidgety and restless 5 - Noticeably restless 6 - Very restless, unable to sit still 7 - Paces back and forth during most of interview, or constantly thrashes about
Tactile Disturbances i Ask: "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" 0 - None 1 - Very 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
Auditory Disturbances i 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?" 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
Visual Disturbances i 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?" 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
Headache / Fullness in Head i Ask: "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. 0 - Not present 1 - Very mild 2 - Mild 3 - Moderate 4 - Moderately severe 5 - Severe 6 - Very severe 7 - Extremely severe
Orientation / Clouding of Sensorium i Ask: "What day is this? Where are you? Who am I?" Ask patient to do serial additions (e.g. count by 7s from 100). 0 - Oriented and can do serial additions 1 - Cannot do serial additions or is uncertain about date 2 - Disoriented to date by no more than 2 calendar days 3 - Disoriented to date by more than 2 calendar days 4 - Disoriented to place or person