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Subjective Opiate Withdrawal Scale (301964-DT)

Subjective Opiate Withdrawal Scale (301964-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #

Index to Questionnaire – Health\Encounter
UWH301964-DT (Rev. 07/11/17) SUBJECTIVE OPIATE WITHDRAWAL SCALE


UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
SUBJECTIVE OPIATE WITHDRAWAL SCALE
(SOWS)


Date:___________________________________ Time:_________________________________ AM/PM

Assessment of Withdrawal from Opioids

PLEASE SCORE EACH OF THE 16 ITEMS BELOW ACCORDING TO HOW YOU FEEL
NOW
(CIRCLE ONE NUMBER)
SYMPTOM
NOT AT ALL A LITTLE MODERATELY QUITE A BIT EXTREMELY
1 I feel anxious
0 1 2 3 4
2 I feel like yawning
0 1 2 3 4
3 I am perspiring
0 1 2 3 4
4 My eyes are teary
0 1 2 3 4
5 My nose is running
0 1 2 3 4
6 I have goosebumps
0 1 2 3 4
7 I am shaking
0 1 2 3 4
8 I have hot flushes
0 1 2 3 4
9 I have cold flushes
0 1 2 3 4
10 My bones and muscles
ache
0 1 2 3 4
11 I feel restless
0 1 2 3 4
12 I feel nauseous
0 1 2 3 4
13 I feel like vomiting
0 1 2 3 4
14 My muscles twitch
0 1 2 3 4
15 I have stomach cramps
0 1 2 3 4
16 I feel like using now
0 1 2 3 4
Range 0-64. Handelsman, L., Cochrane, K. J., Aronson, M. J. et al. (1987)
Two New Rating Scales for Opiate Withdrawal, American Journal of Alcohol Abuse, 13, 293-308.





Signature of Patient/Representative _______________________________Date: ________Time: _________AM/PM

If signed by person other than the patient, print name and state relationship and authority to do so.

Print Name: _____________________________________Relationship: ______________________________

Patient is: Minor Incompetent / Incapacitated
Legal Authority:  Legal Guardian  Parent of Minor  Health Care Agent  Other ___________________


Reviewed by: ___________________________________________Date: ______________ Time: _________AM/PM