Neurological Exam Form

Neurological Exam Form
Patient Name
First NameLast Name
Physician Name
First NameLast Name
Complaint(s) Description
History
Mentation
Other
Attitude
Other
Posture
Gait
Postural Reactions
Rows LF RF LH RH
Proprioception
Hopping
Wheelbarrow
Hemiwalking
Visual placing
Tactile placing
Stairs
Extensor postural thrust
Spinal Reflexes
Rows L R
Flexor (front)
Biceps
Triceps
Patellar
Flexor (rear)
Gastrocnemius
Cranial tibia
Crossed extensor
Cutaneous trunci
- Anal tone/Perineal sensation (1-absent, 2-decreased, 3-normal, 4-increased, 5-clonic)
  
  1
  2
  3
  4
  5
  1 is , 5 is
- Tail tone (1-absent, 2-decreased, 3-normal, 4-increased, 5-clonic)
  
  1
  2
  3
  4
  5
  1 is , 5 is
- Palpation
  Rows Explain
  Cervical Spine:
  Thoracic Spine:
  Lumbar Spine:
  Sacral Spine:
  Musculature:
  Hyperesthesia:
- Sensation
  Rows Explain
  Superficial Pain:
  Deep Pain:
- Neuroanatomical Localization
- Neuroanatomical Localization Notes
- Differential Diagnosis
- Plan
  Rows Check Plan
  Radiographs: 5
  CT 6
  MRI: 7
  CSF Analysis: 8
  EMG 9
- Other Plan(s)
- Date
  MonthDayYear
  Date
- Physician Signature
  Clear
- Should be Empty:

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