Smell of alcohol on breath | | | | | | |
Conjunctival injection and/or flushed face | | | | | | |
Impairment of speech—for example, slurring | | | | | | |
Impairment of motor coordination | | | | | | |
Impairment of attention and/or judgement | | | | | | |
Elated (euphoria) or depressed mood | | | | | | |
Disturbances in behavioural responses | | | | | | |
Disturbances in emotional responses | | | | | | |
Impaired ability to cooperate | | | | | | |
Horizontal gaze nystagmus | | | | | | |
Y91 | Based on the signs above, would you say that the patient is in the state of: (Tick appropriate box) |
Y91.3 | Very severe alcohol intoxication (Very severe disturbance in functions and responses, very severe difficulty in coordination, or loss of ability to cooperate) |
Y91.2 | Severe alcohol intoxication (Severe disturbance in functions and responses, severe difficulty in coordination, or impaired ability to cooperate) |
Y91.1 | Moderate alcohol intoxication |
| (Smell of alcohol on breath, moderate behavioural disturbance in functions and responses, or moderate difficulty in coordination) |
Y91.0 | Mild alcohol intoxication (Smell of alcohol on breath, slight behavioural disturbance in functions and responses, or slight difficulty in coordination) |
Y91.9 | Alcohol involvement, not otherwise specified Please specify reason: Not intoxicated at all |
Do you think that there is any evidence of substance usage other than alcohol? |
| No |
| Yes, based on self report |
| Yes, based on collateral information |
| Yes, based on self report and collateral information |
| Not sure |