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NEUROLOGICAL EVALUATION FORM

Date: Referring Physician: Address: Reason for consult/Visit: Initial Visit Year/ Month / Week / Post-op Follow up Age Right / Left Handed Vitals: B/P / P R T WT HT Allergies: Meds: see med sheet Nurse's Signature: History Form dated today was reviewed with patient. No Changes OR Changes in ROS and/or PFSH are as follows: Chief Complaint: HP1: Context: Quality: Duration: Associated signs/symptoms: Severity: Timing: Modifying factors: Location: Service:

Employment: Tobacco: None/

PHSx:

EXAMINATION CONST: (system) NECK: (area) BACK: (area)

Well developed, well nourished, no acute distress.

Full Range Of Motion: flexion extension, rotation, ateral bend Limited

Full Range Of Motion: flexion extension, rotation, ateral bend Kyphosis Scoliosis

EYES: (system) Discs flat, no hemorrhages or exudates noted. CARD: (system) No Carotid bruits. RRR. no murmurs. No peripheral edema, no varicosities. skin warm MUSCULO: (system) Full range of motion of joints Muscle strength with full resistance to opposition in upper and lower extremities. Firm muscle tone, w/o spasticity, atrophy or abnormal movements in upper and lower extremities.

PSYCH: (system) Pleasant. Appropriate. Alert and oriented x 3 RESP: (system) Respiration non-labored Clear to auscultation bilaterally

SKIN: (system) Clear, no wounds, rashes lesions or ulcers Wounds well healed GAIT: (system) Coordinated and smooth Slow with limp on R / L Able to Heel/Toe walk

Motor: DF PF LE R L

LF HE HF ABD ADD Delt BI Tri WF WE Pro Grip HI

NEUROLOGICAL EVALUATION FORM


NEURO: (system) Recent and remote memory intact. Not easily distracted, concentrates. Speech smooth and clear. Aware of current events Superficial touch and pain sensation intnet bilaterally Deep tendon reflexes 2+ in upper and lower extremities, Dabinski negative. Finger to Nose coordination smooth and accurate CRANIAL NERVES
C2 - Visual fields full. C3-C4-C6 - PERRLA, EOMI Bil C5 - Corneal reflex intact bilat, light, tough & pain sensation nl C7 - Facial movement symmet. C8 - Vibratory sense equal bilat. C9 - Movement of palate equal, uvula midline. Gag reflex intact C11 - Bilat. symmetric 5/5 C 12 - Tongue without asymmetry, atrophy or deviation from midline

Prob. Focused = 1 body area/org. system Exp. Prob. Focused = 2org. systems (including affected body areas) Detailed = 5 org. systems (including affected body area) Comp = 8 org. systems Additional Exam Comments:

Additional Exam Comments:

X-rays ordered today:

No

Yes (Cervical/Thoracic/ Lumbar - AP/Lat, Flex/Ext, Scoliosis, Lateral Bending)

Radiology: MRI/CT/ PLAIN XRAYS/Bone scan Exams: Reviewed:

IMPRESSION:

PLAN: (1) (2) (3)

Resident/Fellow: Date: Teaching/Attending Physician Comments regarding History, &/or Exam, &/or Decision Making:

SEE DICTATION

Attending:

(or other provider)

Date: