Motor Function Neurological Exam Form
Document findings from a motor function neurological examination, including patient details, symptoms, and exam observations.
Patient Full Name
*
First Name
Last Name
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Provider or Source
Presenting Symptoms or Concerns
*
Motor Strength Assessment
*
Please Select
Normal (5/5)
Mild Weakness (4/5)
Moderate Weakness (3/5)
Severe Weakness (2/5)
Paralysis (0-1/5)
Other (specify in notes)
Muscle Tone
*
Please Select
Normal
Increased (Spasticity)
Decreased (Hypotonia)
Rigidity
Other (specify in notes)
Coordination
*
Please Select
Normal
Mild Impairment
Moderate Impairment
Severe Impairment
Other (specify in notes)
Gait and Balance
*
Please Select
Normal
Unsteady
Ataxic
Unable to Walk
Other (specify in notes)
Reflex Observations
*
Please Select
Normal
Hyperreflexia
Hyporeflexia
Absent
Other (specify in notes)
Notable Abnormalities or Examiner Notes
Submit Exam
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