GetWell Physiotherapy Centre

Neurological Assessment Form

DEMOGRAPHIC DATA
Name
Age
Sex
Race
Occupation
Handedness
Date Of Admission

:
:
:
:
:
:
:

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A. SUBJECTIVE EXAMINATION
Chief Complaints: _____________________________________________________________________
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HISTORY:

Present History : _______________________________________________________________

Past History

: _______________________________________________________________

Medical History : _______________________________________________________________

Family History

: _______________________________________________________________

Personal History : _______________________________________________________________

Social History

: _______________________________________________________________

B. OBJECTIVE EXAMINATIONS
ON OBSERVATION:
BUILD:
ATTITUDE OF LIMBS

IN LYING

: _______________________________________________________________

IN SITTING

: _______________________________________________________________

IN STANDING : _______________________________________________________________
POSTURE

AP VIEW

: _______________________________________________________________

PA VIEW

: _______________________________________________________________

LATERAL VIEW : _______________________________________________________________

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GetWell Physiotherapy Centre

Neurological Assessment Form

GAIT ANAYALYSIS: __________________________________________________________________
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DEFORMITIES: _______________________________________________________________________
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ANY EXTERNAL APPLIANCES: __________________________________________________________
ON PALAPATIONS
Tenderness

: ___________________________________________________________________

Skin Temperature : ___________________________________________________________________

Swelling Oedema : ___________________________________________________________________
Clubbing

: ___________________________________________________________________

ON EXAMINATIONS
Higher Mental Functions:
Orientatiion:
Memory:

Short Term : ____________________________________________________________________

Long Term : ____________________________________________________________________

Remote

: ____________________________________________________________________

Behaviour

: ____________________________________________________________________

Speech

: ____________________________________________________________________

Intelligence

:____________________________________________________________________

CRANIAL NERVE ASSESSMENT:

Nerve
I.

Olfactory

Remarks

Nerve

Remarks

VII. Facial

II. Optic

VIII. Vestibulo-Cochlear

III. Oculomotor

IX. Glassopharyngeal

IV. Trochlear

X.

V. Trigeminal

XI. Spinal Accessory

VI. Abducent

XII. Hypoglossal

Vagus

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GetWell Physiotherapy Centre

Neurological Assessment Form

MOTOR EXAMINATIONS
A. Muscle Girth Measurement

: ______________________________________________________

B. Muscle Power

: ______________________________________________________

C. Tone

: ______________________________________________________

Axial

: __________________________________________________________________

Upper Limbs : __________________________________________________________________

Lower Limbs : __________________________________________________________________
VOLUNTARY CONTROL EXAMINATIONS
0 = No response

REFLEXES:

1+ = Low normal or diminished

2+ = Normal
3+ = Brisker than normal. But may not indicate disease
4+ = Hyperactive very brisk spinal cord disorder

Spinal Reflexes

: ____________________________________________________________

Superficial Reflexes : ____________________________________________________________

Abdominal

: ____________________________________________________________

Babinskis Sign

: ____________________________________________________________

DEEP TENDON REFLEXES

BICEPS

: ____________________________________________________________

TRICEPS

: ____________________________________________________________

SUPINATOR

: ____________________________________________________________

KNEE JERK

: ____________________________________________________________

ANKLE JERK

: ____________________________________________________________

MYOTOME TESTING: __________________________________________________________________

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DERMATOME TESTING: _____________________________________________________________

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MUSCLE LENGTH TESTING: ____________________________________________________________
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CONTRACTURES/DEFORMITIES: _______________________________________________________
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GetWell Physiotherapy Centre

Neurological Assessment Form

SENSORY EXAMINATIONS:
SOMATIC:
SUPERFICIAL

LIGHT TOUCH

: _______________________________________________________________

PAIN

: _______________________________________________________________

TEMPERATURE : _______________________________________________________________
DEEP

VIBRATIONS SENSE

: ________________________________________________________

JOINT POSITIONS SENSE : ________________________________________________________

CORTICAL

STEREOGONOSISI : ____________________________________________________________

GRAPHESTHESIA

: ____________________________________________________________

BARAGNOSIS

: ____________________________________________________________

DISCRIMINATIVE

TWO POINT DISCRIMINATION: _____________________________________________________
DERMATOME TESTING: _______________________________________________________________
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ROM MEASUREMENT
UPPER LIMB:
MUSCLE

RIGHT

LEFT

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GetWell Physiotherapy Centre

Neurological Assessment Form

LOWER LIMB:
MUSCLE

RIGHT

LEFT

MUSCLE

RIGHT

LEFT

SPINE:

LIMB LENGTH MEASUREMENT:

TURE

: __________________________________________________________________

APPARENT : __________________________________________________________________
ABNORMAL MOVEMENTS:
BALANCE AND CO-ORDINATIONS
BALANCE

STATIC

: __________________________________________________________________

DYNAMIC : __________________________________________________________________
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GetWell Physiotherapy Centre

Neurological Assessment Form

CO-ORDINATION

Finger to Nose Test : ___________________________________________________________

Dysdiadokokinesia

: ___________________________________________________________

Heel to Shin

: ___________________________________________________________

Wash Basin Sign

: ___________________________________________________________

Rombergs Sign

: ___________________________________________________________

Tandem Walking

: ___________________________________________________________

BLADDER/BOWEL CONTROL: __________________________________________________________

CARDIO RESPIRATORY
VITAL SIGNS

Temperature

: _______________________________________________________________

Pulse Rate

: _______________________________________________________________

Respiratory Rate : _______________________________________________________________

Blood Pressure

: _______________________________________________________________

Breathing Pattern : ____________________________________________________________________

Chest Expansion : ____________________________________________________________________
Chest Deformity

: ____________________________________________________________________

Auscultation

: ____________________________________________________________________

Lung Secretions : ____________________________________________________________________

GASTROINTESTINAL EXAMINATIONS:
FUNCTIONAL ACTIVITY EXAMINATION

Eating

: _____________________________________________________________________

Drinking : _____________________________________________________________________

Bathing

: _____________________________________________________________________

Toileting : _____________________________________________________________________

Combing : _____________________________________________________________________
PROVISIONAL DIAGNOSIS : __________________________________________________________
DIFFERENTIAL DIAGNOSIS : __________________________________________________________
INVESTIGATIONS

: __________________________________________________________

DIAGNOSIS

: __________________________________________________________

PROBLEM LISTING

: __________________________________________________________

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GPC

GetWell Physiotherapy Centre

Neurological Assessment Form

PLAN OF TRETMENT
SHORT TERM GOAL:

LONG TERM GOAL:

PHYSIOTHERAPY MANAGEMENT:
Electrotherapy: ______________________________________________________________________
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Exercise therapy: _____________________________________________________________________
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Home Exercises: _____________________________________________________________________
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GPC