Measured after patient is sitting or lying for one minute.

• Pulse rate 80 or below 0
• Pulse rate 81-100 1
• Pulse rate 101-120 2
• Pulse rate greater than 120 4

Over last 30 minutes

• No GI symptoms 0
• Stomach cramps 1
• Vomiting or diarrhea 3
• Multiple episodes of diarrhea or vomiting 5

Over past 30 minutes not accounted for by room temperature or patient activity

• No report of chills or flushing 0
• Subjective report of chills or flushing 1
• Flushed or observable moistness on face 2
• Beads of sweat on brow or face 3
• Sweat streaming off face 4

Observation of outstretched hands

• No tremor 0
• Tremor can be felt, but not observed 1
• Slight tremor observable 2
• Gross tremor or muscle twitching 4

Observation during assessment

• Able to sit still 0
• Reports difficulty sitting still, but is able to do so 1
• Frequent shifting or extraneous movements of legs/arms 3
• Unable to sit still for more than a few seconds 5

Observation during assessment

• No yawning 0
• Yawning once or twice during assessment 1
• Yawning three or more times during assessment 2
• Yawning several times/minute 4

Observation during assessment

• Pupils pinned or normal size for room light 0
• Pupils possibly larger than normal for room light 1
• Pupils moderately dilated 2
• Pupils so dilated that only the rim of the iris is visible 5

• None 0
• Patient reports increasing irritability or anxiousness 1
• Patient obviously irritable or anxious 2
• Patient so irritable or anxious that participation in the assessment is difficult 4

If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored

• Not present 0
• Mild diffuse discomfort 1
• Patient reports severe diffuse aching of joints/muscles 2
• Patient is rubbing joints or muscles and is unable to sit still because of discomfort 4

Not accounted for by cold symptoms or allergies

• Not present 0
• Nasal stuffiness or unusually moist eyes 1
• Nose running or tearing 2
• Nose constantly running or tears streaming down cheeks 4

• Skin is smooth 0
• Piloerrection of skin can be felt or hairs standing up on arms 3
• Prominent piloerrection 5