Neurological Exam Form
Patient Name
First Name
Last Name
Physician Name
First Name
Last Name
Complaint(s) Description
History
Mentation
Normal
Sedate
Obtunded
Stuporous
Comatose
Other
Attitude
Normal
Aggressive
Excited
Anxious
Apathetic
Circling left
Circling right
Other
Posture
Normal
Head Tilt Left
Head Tilt Right
Schiff-Sherrington
Decerebellate
Torticollis
Kyphosis
Wide-based
Gait
Normal
Lameness
Hemiparesis
Monoparesis
Paraparesis
Paraplegia
Tetraparesis
Tetraplegia
General Proprioceptive
Vestibular
Cerebellar
Postural Reactions
LF
RF
LH
RH
Proprioception
Hopping
Wheelbarrow
Hemiwalking
Visual placing
Tactile placing
Stairs
Extensor postural thrust
Spinal Reflexes
L
R
Flexor (front)
Biceps
Triceps
Patellar
Flexor (rear)
Gastrocnemius
Cranial tibia
Crossed extensor
Cutaneous trunci
Lumbosacral Reflexes
Anal tone/Perineal sensation (1-absent, 2-decreased, 3-normal, 4-increased, 5-clonic)
1
1
2
3
4
2
5
1 is , 5 is
Tail tone (1-absent, 2-decreased, 3-normal, 4-increased, 5-clonic)
3
1
2
3
4
4
5
1 is , 5 is
Palpation
Explain
Cervical Spine:
Thoracic Spine:
Lumbar Spine:
Sacral Spine:
Musculature:
Hyperesthesia:
Sensation
Explain
Superficial Pain:
Deep Pain:
Neuroanatomical Localization
Neuroanatomical Localization Notes
Differential Diagnosis
Vascular
Inflammatory, infectious, immune-mediated
Traumatic/Toxic
Anomalous/Congenital
Metabolic
Idiopathic/Iatrogenic
Neoplastic/Nutritional
Degenerative
Plan
Check
Plan
Radiographs:
5
CT
6
MRI:
7
CSF Analysis:
8
EMG
9
Other Plan(s)
Date
-
Month
-
Day
Year
Date
Physician Signature
Submit
Should be Empty: