Version August 2025
| Symptoms | Score for "yes" response |
| Anxiety: Do you feel that something bad is about to happen to you right now? | 3 |
| Nausea and dry heaves or vomiting? | 3 |
| Sweating (includes moist palms, sweating now)? | 2 |
| Tremor (with arms extended, eyes closed)? | 2 |
| Agitation: Fidgety, restless, pacing? | 3 |
| Disorientation: | |
| Knows name and place but not date? | 1 |
| Knows name only? | 3 |
| Hallucinations: | |
| Auditory only? | 1 |
| Visual, tactile, olfactory, gustatory (any)? | 3 |
| Vital signs: Any of the following? Pulse >110, diastolic blood pressure >90, temperature >99.6 °F (or 37.6°C)? | 3 |
| Total score | |
