NEUROSURGERY ASSESSMENT PROFORMA

Patient details Assessment date:

Name: ...................................................................... Reassessment date:

Address: ...................................................................
Tel number: ................................. Age: ................

Consultant:

Diagnosis:

Proposed Operation:

Current Symptoms:

Past Medical History:

Add any additional comments...

Drug & Allergy History:

Add any additional comments...

Is the patient taking aspirin/warfarin/clopidogrel? Yes No

If yes, give details and action required ...........................................................................

Social History:
Add any additional comments...

Occupation:

Hand Dominance:

1
Overall Appearence:

Cardiovascular System:

Respiratory System:

Gastrointestinal System:

Neurological Examination:

Cranial Nerves:
Right Left

I Olfactory
II Fundi
Visual acuity

Visual fields

III IV VI Pupil size

Direct
Consensual
Accommodation
Eye movements

V Motor
Sensory
Corneal reflex
ALWAYS TEST CORNEAL REFLEXES IN ‘TRIGEMINAL’ PATIENTS

VII Motor
VIII Hearing

IX X Gag reflex
XI Shoulder shrug
XII Tongue

Neck movements:

2
Upper Limbs:
Right Left

Inspection
Tone
Power Shoulder abduction
Shoulder adduction
Elbow flexion
Elbow extension
Wrist flexion
Wrist extension
Finger absuction
Finger adduction
Reflexes Triceps
Biceps
Supinator
Co-Ordination
Hoffman’s

Lower Limbs:
Right Left

Inspection
Tone
Power Hip flexion
Hip extension
Knee flexion
Knee extension
Ankle dorsiflexion
Ankle plantarflexion
EHL
FHL
Reflexes Knee
Ankle
Plantars
Co-Ordination
Straight Leg Raise

Gait:

Sensation: Fully intact 

Some abnormal findings (document overleaf) 

3
4
Investigations: (please tick)

FBC  Chest X-ray TFTs (inc T3)

Pituitary Function bloods

Creatinine ECG (everyone over 50) Prolactin
LFTs  ECHO IGF-1
Bone Profile Spirometry LH
Clotting screen  Pulmonary fuction FSH
Group & save  C-Spine X-rays Testosterone
Sickle cell T-Spine X-rays ACTH
Glucose  L-Spine X-rays Cortisol
Others (please state) Serum HBG

Anaesthetic Review:
Is not required 
Is required (state reason/question to be answered below) 

Results:

Hb Na T3
WCC K T4
Plts Creat TSH
INR Urea Prolactin
PT Glucose IGF-1
APTT Cortisol LH
Serum HBG FSH
Testost
ACTH

ECG

CXR

Final Checklist:

 Drug chart? Yes 

 ‘Results’ section completed? Yes 
 Patient fit for surgery? Yes  No 

Pre-assessment performed by: Date:

Results checked by: Date:

Re-assessment performed by: Date: