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

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B. OBJECTIVE EXAMINATIONS
ON OBSERVATION:
BUILD:
ATTITUDE OF LIMBS
IN LYING
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IN SITTING
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IN STANDING : _______________________________________________________________
POSTURE
AP VIEW
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PA VIEW
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LATERAL VIEW : _______________________________________________________________

GAIT ANAYALYSIS: __________________________________________________________________

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GetWell Physiotherapy Centre

Neurological Assessment Form

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DEFORMITIES: _______________________________________________________________________
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ANY EXTERNAL APPLIANCES: __________________________________________________________
ON PALAPATIONS
Tenderness

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Skin Temperature : ___________________________________________________________________

Swelling Oedema : ___________________________________________________________________
Clubbing

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ON EXAMINATIONS
Higher Mental Functions:
Orientatiion:
Memory:
Short Term : ____________________________________________________________________
Long Term : ____________________________________________________________________
Remote
: ____________________________________________________________________
Behaviour
: ____________________________________________________________________
Speech
: ____________________________________________________________________
Intelligence
:____________________________________________________________________
CRANIAL NERVE ASSESSMENT:
I.
II.
III.
IV.
V.
VI.

Nerve
Remarks
Nerve
Remarks
Olfactory
VII. Facial
Optic
VIII. Vestibulo-Cochlear
Oculomotor
IX. Glassopharyngeal
Trochlear
X. Vagus
Trigeminal
XI. Spinal Accessory
Abducent
XII. Hypoglossal
MOTOR EXAMINATIONS
A. Muscle Girth Measurement : ______________________________________________________
B. Muscle Power
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C. Tone
: ______________________________________________________
Axial
: __________________________________________________________________
Upper Limbs : __________________________________________________________________
Lower Limbs : __________________________________________________________________
0 = No response

VOLUNTARY CONTROL EXAMINATIONS

1+ = Low normal or diminished

2+ = Normal

3+ = Brisker than normal. But may not indicate disease

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4+ = Hyperactive very brisk spinal cord disorder
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GetWell Physiotherapy Centre

Neurological Assessment Form

REFLEXES:

Spinal Reflexes
Superficial Reflexes
Abdominal
Babinskis Sign

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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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SENSORY EXAMINATIONS:
SOMATIC:
SUPERFICIAL
LIGHT TOUCH : _______________________________________________________________
PAIN
: _______________________________________________________________
TEMPERATURE : _______________________________________________________________
DEEP
VIBRATIONS SENSE
: ________________________________________________________
JOINT POSITIONS SENSE : ________________________________________________________
CORTICAL
STEREOGONOSISI : ____________________________________________________________
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GetWell Physiotherapy Centre

Neurological Assessment Form

GRAPHESTHESIA
BARAGNOSIS

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

RIGHT

LEFT

MUSCLE

RIGHT

LEFT

LOWER LIMB:

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GetWell Physiotherapy Centre

Neurological Assessment Form

SPINE:
MUSCLE

RIGHT

LEFT

LIMB LENGTH MEASUREMENT:

TURE
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APPARENT : __________________________________________________________________
ABNORMAL MOVEMENTS:
BALANCE AND CO-ORDINATIONS
BALANCE
STATIC
DYNAMIC

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CO-ORDINATION

Finger to Nose Test

Dysdiadokokinesia
Heel to Shin
Wash Basin Sign
Rombergs Sign
Tandem Walking

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BLADDER/BOWEL CONTROL: __________________________________________________________

CARDIO RESPIRATORY
VITAL SIGNS

Temperature
Pulse Rate
Respiratory Rate
Blood Pressure

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GetWell Physiotherapy Centre

Neurological Assessment Form

Breathing Pattern : ____________________________________________________________________
Chest Expansion : ____________________________________________________________________
Chest Deformity

: ____________________________________________________________________

Auscultation

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Lung Secretions : ____________________________________________________________________

GASTROINTESTINAL EXAMINATIONS:
FUNCTIONAL ACTIVITY EXAMINATION

Eating
Drinking
Bathing
Toileting
Combing

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PROVISIONAL DIAGNOSIS : __________________________________________________________

DIFFERENTIAL DIAGNOSIS : __________________________________________________________
INVESTIGATIONS

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DIAGNOSIS

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PROBLEM LISTING

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PLAN OF TRETMENT
SHORT TERM GOAL:

LONG TERM GOAL:

PHYSIOTHERAPY MANAGEMENT:
Electrotherapy: ______________________________________________________________________
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GetWell Physiotherapy Centre

Neurological Assessment Form

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Exercise therapy: _____________________________________________________________________
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Home Exercises: _____________________________________________________________________
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