Criteria | Finding | Points |
Crying | None | 0 |
Consolable | 1 | |
Not consolable | 2 | |
Movement | None | 0 |
Restless | 1 | |
Thrashing | 2 | |
Agitation | Asleep | 0 |
Calm | 0 | |
Mild | 1 | |
Hysterical | 2 | |
Posture | Normal | 0 |
Flexed | 1 | |
Holds injury site | 2 | |
Verbal | Asleep | 0 |
No complaint | 0 | |
Complains but cannot localize | 1 | |
Complains and can localize | 2 |