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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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GPC

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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GPC

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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GPC

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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GPC

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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GPC

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