0920-1011 Neurologial Examination Form

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2020

Neurologic Exam Form
Final

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Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

NEUROLOGIC EXAM FORM
Patient data (remove top page following exam)
Patient’s Name:

PATIENT ID ___ ___ ___ ___
First Name

Last Name
Date of Birth:

_______/_______/_______
MM

Tribal community:

DD

Gender:

M

YYYY

Tribal affiliation:

FINAL

F

NEUROLOGIC EXAM FORM
PATIENT ID ___ ___ ___ ___

Date of RMSF onset:

Age at illness (years):______

_______/_______/_______
MM

DD

Neurologic exam completed?
If yes,

Yes

Date of exam:

If no, why not?

Deceased

I. Altered mental status

Current age (years): _____

YYYY

No

_______/_______/_______
MM

DD

Lost to follow up

Altered

Did not consent

Normal

Provider performing exam: __________________________________

YYYY

Other, describe: _______________________________________________________

Unknown/Unable to determine

(If altered or unknown, proceed to II. Mental status examination, otherwise skip to III. Language)

II. Mental status (8 years and older) (as determined by the healthcare provider using the Montreal Cognitive Assessment (MOCA))
(If less than 8 years skip to section IV, cranial nerve assessment.)
Visuospatial/executive:

(5)

Attention:

(6)

Abstraction:

(2)

Orientation

(6)

Naming:

(3)

Language:

(3)

Delayed recall

(5)

TOTAL:

(30)

III. Language (8 years and older)
Normal

Expressive aphasia

Global aphasia

Receptive aphasia

Dysarthria

Description of difficulty:

IV. Cranial nerves
CN I

Normal

Abnormal, describe: __________________________________

CN II
Pupil exam

Normal

Abnormal, describe: ____________________

Accommodation

Normal

Abnormal, describe: ____________________

Visual field

Normal

Visual acuity
Fundoscopic exam

CN VI

Normal

Abnormal, describe: __________________________________

CN VII

Normal

Abnormal, describe: ___________________________________

CN VIII

Normal

Abnormal, describe: __________________________________

Abnormal, describe: ____________________

CN IX

Normal

Abnormal, describe: __________________________________

Normal

Abnormal, describe: ____________________

CN X

Normal

Abnormal, describe: __________________________________

Normal

Abnormal, describe: ____________________

CN XI

Normal

Abnormal, describe: __________________________________

CN XII

Normal

Abnormal, describe: __________________________________

CN III

Normal

Abnormal, describe: __________________________________

CN IV

Normal

Abnormal, describe: __________________________________

CN V

Normal

Abnormal, describe: __________________________________

V. Sensory
Upper extremities

Normal

Numbness

Paresthesias

Other, describe: _______________________________________________________

Lower extremities

Normal

Numbness

Paresthesias

Other, describe: _______________________________________________________

Core

Normal

Numbness

Paresthesias

Other, describe: _______________________________________________________

Face

Normal

Numbness

Paresthesias

Other, describe: _______________________________________________________

VI. Motor
A. Abnormal movements
Fasiculations

Yes

No

Comments: ___________________________________________________

Tremor

Yes

No

Comments: ___________________________________________________

Chorea/dyskinesias

Yes

No

Comments: ___________________________________________________

Myoclonus

Yes

No

Comments: ___________________________________________________

B. Bulk
Atrophy

Yes

No

Comments: ___________________________________________________

Upper extremities

Normal

Increased (spastic or rigid)

Decreased

Comments: ___________________________________________________

Lower extremities

Normal

Increased (spastic or rigid)

Decreased

Comments: ___________________________________________________

Core

Normal

Increased (spastic or rigid)

Decreased

Comments: ___________________________________________________

C. Tone

D. Other upper motor neuro signs
R

L

Pronator drift

Yes

No

Yes

No

Comments: ___________________________________________________

Finger tap speed

Normal

Slow

Normal

Slow

Comments: ___________________________________________________

Foot tap speed

Normal

Slow

Normal

Slow

Comments: ___________________________________________________

NEUROLOGIC EXAM FORM
PATIENT ID ___ ___ ___ ___
E. Strength (0 = No movement; 1 = Barely discernable movement; 2 = Movement along plane of gravity; 3 = Movement against gravity; 4 = Movement against
resistance; 5 = Normal)

Neck flexors
Neck extensors

Lower extremity:
R

_______________

L
Hip flexors

_______________

Hip extensors

Upper extremity:
R

L

Hip abduction

Deltoids

Hip adduction

Biceps

Quadriceps

Triceps

Hamstrings

Wrist extensors

Plantarflexors

Wrist flexors

Dorsiflexors

Finger extensors

Foot evertors

Finger flexors

Foot invertors

Abductor pollicis brevis

Extensor hallucis longus

Opponens pollicis

Toe flexors

Interossei

Toe extensors

VII. Reflexes (0 = Absent; 1 = Decreased; 2 = Normal; 3 = Increased/hyperactive; 4 = sustained clonus)
R

L
Excessive jaw jerk

Brachioradialis

Yes

Biceps

No

R

Triceps

Sustained ankle clonus

Patellar

Plantar response
(Babinski)

Yes
Up

L

No
Down

│
Unclear │

Yes
Up

No

Down

Unclear

Ankle jerk

VIII. Coordination

R

Comments:

L

Finger-to-nose

Normal

Dysmetric

Other

Normal

Dysmetric

Other

______________________________________

Heel-knee-shin

Normal

Dysmetric

Other

Normal

Dysmetric

Other

______________________________________

Past-pointing

Normal

Overshoot

Other

Normal

Overshoot

Other

______________________________________

Check reflex

Normal

Loss of check reflex

Normal

Loss of check relfex

Other

Other ______________________________________

IX. Gait and station
Spontaneous gait

Normal

Hemiplegic

Able to walk on toes

Yes

No

Able to walk on heels

Yes

No

Able to tandem

Yes

No

Romberg

Positive

Negative

Steppage

Shuffling

Other, describe: _______________________________________________________

Unable to assess

X. Additional narrative/comments:

Modified Rankin Scale (Determined by healthcare provider at exam)
Use pediatric modified Rankin for children less than 8 years of age (appendix A)
0 = No symptoms at all
1 = No significant disability despite symptoms; able to carry our all usual duties and activities
2 = Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance
3 = Moderate disability; requiring some help, but able to walk without assistance
4 = Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
5 = Severe disability; bedridden, incontinent and requiring constant nursing care and attention
6 = Dead

SCORE (0 – 6):

_____________

NEUROLOGIC EXAM FORM
PATIENT ID ___ ___ ___ ___

Appendix A: Modified Rankin Scale for children