Neurological Assessment (100) - (7) up to five times (93, 86,79...) Cbraw a clock (make the time 12:30) ‘Comments Patient Namo: Date: DoB: Age: Sex: Gender: Insurance: CC & Significant History: Key Consideration THeadache [1 Dizziness/Vertigo [Tremors 1 Incoordination 1 Ditficutty Swallowing Dead injury 1] Seizures [Weakness C]Numbness/Tingling [1 Dificulty Speaking Significant Past History [Environmental Hazards [J Other: [1 Reter to secondary consult TL Reter to diagnostic imaging: Mental Status C1 WNL (Within Normal Limits) Development Good OFeir Poor Behavior Datet LAtethargic ~— L)contusion Speech Orientation OTime OPerson (Place & Situation Memory/Concentration [Name presidentrecent newsworthy events [13 word or place recall at 0 and § minutes CO Spell word backwards 1 Draw overlapping pentagons For the remaining sections, N Normal, A = Abnormal. If Abnormal, Describe in Comments Section Reflexes CW (within Normal Limits) DTR (Rate from 0-4) Right Left Pathologie Right Left Bicops (C5), Babinski On Ga On Oa Brachioradalis (C8) ‘Abdominal ON Ga On Oa Triceps (C7) Hotfman’s On Oa On Oa Patella (L4) Hamstring (L5) Achilles (S1) ‘Comments hitps:/Carepatron.com me WMearepatronMotor Function TOWNE (within Normal Limits) Motor (Rate from 0-5) Right Left Comments Doltoid (C5, C8) (axiary) Brachioradialis (C5, C6) (radial) Biceps (C5, C6) (musculocut.) Triceps (C6, C7, C8, Tt) (radial) Wrist flexors (C6, C7) (med /ulnar) Wrist extensors (C6, C7, C8) (rad.) Interossel (C7, C8, T1) (ulnar) Tib. anterior (L4, L5) (deep per.) Extensor hallucis longus (L4, L5, 51) (deep peroneal) Fibularis (peroneus) longus (L5, $1) (superficial peroneal) Cranial Nerve 1 WAL (Within Normal Limits) 1- Olfactory Right Lett Vil- Facial Right Lett Scont #1 On Oa On Oa Facial expressions ON Oa On OA Scent #2 On Oa On Oa Facial expression#2 CN Oa ON OA atone cr a Normal eye movement CIN OA ON QA Visual acuity On oa on oa Vill Vestibulocochlear Right Lett Visual fields On Oa On Oa Rhomberg's test On Oa On Oa Fundoscopyoram = =ON Oa On OA ‘Auditory acuity On Oa On oa tm, IV, VI Right Left ‘Weber On Oa On OA “H pattern On Oa ON OA oe On Oa On Oa ‘Convergence ON OA ON OA IX, x Right Left Nystagmus On OA ON OA Gag reflex On Oa ON OA Consensual light reflex CIN OA ON OA Elevation of palate On Oa On Oa V- Trigeminal Right Lett XI- Spinal Accessory Right Lett Lateral law deviation CN OA CIN DA Trapezius muscle test CIN [JA CIN LA Masseter contraction CIN Oa CIN DA SCM muscle test ON oa on oa N Face sensation CNN XIl- Hypoglossal Right Left Corneal touch reflex CIN Cla CIN Oa Sa Cot on Oa on ca Comments Cerebellar (WAL (Within Normal Limits) Right Lett Right Lett Rapid finger movement [IN CA CIN [A Heel down shin On Oa On Oa Rapid provsupinaton [JN [JA CIN OA Holme's rebound sion CON OA ON OA Finger-to-noselfinger [JN [JA [IN [A Gaitiheel-toe walk ON oaon oa ‘Comments hitps/Carepatron.com ress’ @PcarepatronNerve Tension WN (within Normal Limits) Right Left Right Left Straight Leg Raise On Oa ON Oa Median nerve traction [JN [JA CIN DA Maximal SLR On Ga On oa Radialnervetraction CIN Ola ON OA Bragard’s. On Oa On Oa Ulnar nerve traction [JN OA ON OA Femoral nerve traction CIN OA ON OA Tinel's On oa On oa ‘Comments Sensory C1WNt (within Normal Limits) Right Left Right Left Light touch On oa on oa Position sense On ga on oa Vibration On Oa On OA Proprioception On Oa On OA Stereognosis On Oa ON Oa Romberg On Oa On Oa Graphesthesia On oa on oa Sharp/Dull On ga on oa 2:point discrim On OA on oa HovCold On oa on oa ‘Comments Differential Diagnosis Additional Comments Signatur Date hitps:/Carepatron.com me WMearepatron