II. Grading: Criteria (score 1 point for each positive criteria, 6 possible points)

  1. Confusion
  2. Irritability
  3. Boisterousness
  4. Physical Threats
  5. Verbal Threats
  6. Attacks on Objects

III. Interpretation

  1. Score 0: Low risk of Violence
  2. Score 1-2: Moderate risk of Violence
  3. Score >=3: High risk of Violence

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