| DATE (month/day) | |
| TREMOR: (Assess with Arms Extended and Fingers Apart) 0 = no tremor 1 = tremor not visibly apparent, can be felt by placing fingertips lightly against patient’s fingertips 4 = tremor is moderate 7 = marked tremor even when arms are not extended |
|
| PAROXYSMAL SWEATS: (At Time of Observation) 0 = no sweat visible 1 = barely perceptible sweating, palms moist 4 = beads of sweat obviously observable on forehead 7 = drenching sweats |
|
| CLOUDING OF SENSORIUM: (At Time of Observation) 0 = no evidence of clouding of sensorium 1 = cannot do serial 7 subtractions or is uncertain about date 2 = disoriented for date by no more than 2 calendar days 3 = disoriented for date by more than 2 calendar days 4 = disoriented for place and/or person |
|
| AGITATION/RESTLESSNESS: (Based on Present Movement. Do not confuse with anxiety or tremor.) 0 = normal activity 1 = somewhat more than normal activity 4 = moderately fidgety and restless 7 = paces back and forth during most of the interview, or thrashing about constantly |
|
| PULSE: (At Time of Observation) | |
| 0 = 89 or below | 4 = 105-109 |
| 1 = 90-94 | 5 = 110-114 |
| 2 = 95-99 | 6 = 115-119 |
| 3 = 100-104 | 7 = 120 & higher |
| NAUSEA & VOMITING: (Ask, "Do you feel sick to your stomach? Have you vomited?" Observation.) 0 = no nausea and no vomiting 1 = mild nausea with no vomiting 4 = intermittent nausea with dry heaves 7 = constant nausea, frequent dry heaves and vomiting |
|
| ANXIETY: (Ask, "Do you feel nervous?" Observation.) 0 = no anxiety, at ease 1 = mildly anxious 4 = moderately anxious, or guarded, so anxiety is inferred 7 = equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions |
|
Source: Barry, K.L.; Oslin, D.W.; and Blow, F.C. Alcohol Problems in Older Adults: Prevention and Management. New York: Springer Publishing, 2001.