| Headache |
| 0: Not present |
| 1: Very mild |
| 2: Mild |
| 3: Moderate |
| 4: Moderately severe |
| 5: Severe |
| 6: Very severe |
| 7: Extremely severe |
| Auditory disturbances |
| 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 |
| 0: Not present |
| 1: Very mild photosensitivity |
| 2: Mild photosensitivity |
| 3: Moderate photosensitivity |
| 4: Moderately severe visual hallucinations |
| 5: Severe visual hallucinations |
| 6: Extremely severe visual hallucinations |
| 7: Continuous visual hallucinations |
| Tactile disturbances |
| 0: None |
| 1: Very mild paresthesias |
| 2: Mild paresthesias |
| 3: Moderate paresthesias |
| 4: Moderately severe hallucinations |
| 5: Severe hallucinations |
| 6: Extremely severe hallucinations |
| 7: Continuous hallucinations |
| Orientation and clouding of sensorium |
| 0: Oriented and can do serial additions |
| 1: Cannot do serial additions |
| 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 patient |
| Total score is a simple sum of each item score (maximum score is 67) |
| Score: |
| <10: Very mild withdrawal |
| 10 to 15: Mild withdrawal |
| 16 to 20: Modest withdrawal |
| >20: Severe withdrawal |
