| Patient's name:_______________ | Date and time:___/___/___:______ |
| Reason for this assessment:_________________________ | |
| Resting pulse rate:__________beats/minute Measured after patient is sitting or lying for one minute | GI upset: Over last half-hour |
| 0 pulse rate 80 or below 1 pulse rate 81 to 100 2 pulse rate 101 to 120 4 pulse rate greater than 120 | 0 no GI symptoms 1 stomach cramps 2 nausea or loose stool 3 vomiting or diarrhea 5 multiple episodes of diarrhea or vomiting |
| Sweating: Over past half-hour not accounted for by room temperature or patient activity | Tremor: Observation of outstretched hands |
| 0 no report of chills or flushing 1 subjective report of chills or flushing 2 flushed or observable moistness on face 3 beads of sweat on brow or face 4 sweat streaming off face | 0 no tremor 1 tremor can be felt, but not observed 2 slight tremor observable 4 gross tremor or muscle twitching |
| Restlessness: Observation during assessment | Yawning: Observation during assessment |
| 0 able to sit still 1 reports difficulty sitting still, but is able to do so 3 frequent shifting or extraneous movements of legs/arms 5 unable to sit stil l for more than a few seconds | 0 no yawning 1 yawning once or twice during assessment 2 yawning three or more times during assessment 4 yawning several times/minute |
| Pupil size | Anxiety or irritability |
| 0 pupils pinned or normal size for room light 1 pupils possibly larger than normal for room light 2 pupils moderately dilated 5 pupils so dilated that only the rim of the iris is visible | 0 none 1 patient reports increasing irritability or anxiousness 2 patient obviously irritable or anxious 4 patient so irritable or anxious that participation in the assessment is difficult |
| Bone or joint aches: If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored | Gooseflesh skin |
| 0 not present 1 mild diffuse discomfort 2 patient reports severe diffuse aching of joints/muscles 4 patient is rubbing joints or muscles and is unable to sit still because of discomfort | 0 skin is smooth 3 piloerrection of skin can be felt or hairs standing up on arms 5 prominent piloerrection |
| Runny nose or tearing: Not accounted for by cold symptoms or allergies | Total score:__________ The total score is the sum of all 11 items |
| 0 not present 1 nasal stuffiness or unusually moist eyes 2 nose running or tearing 4 nose constantly running or tears streaming down cheeks | Initials of person completing assessment:__________ |
