COMPREHENSIVE NEUROLOGICAL ASSESSMENT

Referred By: Date:

Name:........................................................ Age/Sex................ Handedness: .........................................................

Address:.....................................................................................................................................................................
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Phone Number:..................................................... email:.........................................................................................
Occupation:................................................................................................................................................................

CHIEF COMPLAINT
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HISTORY TAKING
History of Present Illness
 Onset of Illness (Sudden/Gradual)..........................................................................................................................
 Duration of Illness: .........................................................................................................................................................
 Nature of Symptoms......................................................................................................................................................
 Severity: (Mild/ Moderate/ Severe).......................................................................................................................
 Frequency of symptoms: (Constant / Intermittent).......................................................................................
 Type of Illness (Progressive/ Regressive/ Stable)...........................................................................................
 History of Relapse..........................................................................................................................................................
 Description of Previous Treatment Taken..........................................................................................................
 Effect of Treatment: (Beneficial/ Non Beneficial/ Stable)............................................................................
 Seasonal Variation.........................................................................................................................................................
 Diurnal Variation............................................................................................................................................................
 Predisposing Factors....................................................................................................................................................

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 Relieving Factors............................................................................................................................................................
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 Functional Limitations Due to Illness...................................................................................................................
Past Medical History

 History of Infections, Allergies, Seizures, Head Injuries, Diabetes, Hypertension Neurological

episodes similar to the presenting complaint, Previous Hospitalizations, Persistant
Disabilities...........................................................................................................................................................................
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Family History

 Patient’s first degree relatives i.e. parents, siblings and children (Ages, Sex and
Health).......................................................................................................................................................
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Personal & Social History

 Alcohol Intake (in number of units per week):-

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 Smoking in pack years (packs per day times years smoked):-
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 Addiction to Drug:-
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 Social environment Home caregivers and community:-
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Occupational History

 Current Illness Has Affected Work And Social Life Including Time Lost From Work Over The Last
6 Months:-
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OBJECTIVE EXAMINATION

 Built: ....................................................................................................................................................................................................
 Attitude of limbs: ...........................................................................................................................................................................
 Posture: .............................................................................................................................................................................................
 Pattern of Movement: .................................................................................................................................................................
 Gait: .....................................................................................................................................................................................................
 Muscle Wasting: .............................................................................................................................................................................
 Oedema: .............................................................................................................................................................................................
 Pressure Sores: ...............................................................................................................................................................................
 Deformity: .........................................................................................................................................................................................
 Wounds: .............................................................................................................................................................................................
 External Appliances: .....................................................................................................................................................................
 Involuntary Movements: .............................................................................................................................................................

EXAMINATION OF HIGHER MENTAL FUNCTIONS

 General Appearance/ Behaviour:-
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 Dressing:-
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 Personal Hygiene:-
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 Eye to Eye Contact:-
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 Interactive:-
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 General Mood:-
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 Mood Variations:
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 Hallucinations:-

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EXAMINATION OF COGNITIVE FUNCTIONS
Stage of Consciousness:-
 Full consciousness/Lethargy/Obtundation /Stupor/Coma……………………………………………………
……………………………………………………………………………………………………………………………………………

Level of Consciousness (Glasgow Coma Scale)

Response of the Patient Score Patiient’s

Score
Spontaneous eye opening 4

To verbal stimuli, command, speech 3

Eye Response
To pain only 2

No response 1

Oriented 5

Confused conversation, but able to answer questions 4

Verbal Inappropriate words 3
Response
Incomprehensible speech 2

No response 1

Obeys commands for movement 6

Purposeful movement to painful stimulus 5

Withdraws in response to pain 4

Motor
Response Flexion in response to pain (decorticate posturing) 3
Extension response in response to pain (decerebrate
2
posturing
No response 1 pain 1

TOTAL SCORE

Teasdale G, Jennett B (1974). "Assessment of coma and impaired consciousness. A practical scale". Lancet. 2 (7872): 81–4

Orientation
 Person:-
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  Place:-
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 Time:-
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Memory

 Registration:-
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 Working Memory
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 Recent Memory:-
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 Remote Memory:-
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Attention:-

 Sustained Attention
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 Divided Attention
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 Selective Attention
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 Alternating Attention
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Other Remarks
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Abstract Thinking:-
 Similarities/Differences/Proverbs:-
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Arithmatic Calculations:-
 Summation/Subtraction/Multiplication:-
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Examination of Speech:-
Components of Speech Remarks

Speech Sounds

Initiation

Fluency

Slurring

Stammering

Comprehension

Repetition.

Naming

Hoarseness

Pitch

Signs of Breathlessness while speaking

Fatigue associated with speech

Pronunciation of (Labials/Dentals/Dentolabials/lingualsetc)

Examination of Perceptual Functions:-

 Visual Perception Assessment (Agnosias):-
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 Visual-Spatial Perception Assessments:-
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 Tactile Perception Aception assess:-
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 Body scheme Perception:-
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 Motor Perception assessment (Apraxia):-
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EXAMINATION OF CRANIAL NERVES

No.
Name of the Cranial Nerve Right Left
I
Olfactory
II
Optic
III
Occulomotor
IV
Trochlear
V
Trigeminal
VI
Abducens
VII
Facial
VIII
Vestibulocochlear Nerve
IX
Glossopharyngeal
X
Vagus
XI
Spinal Accessory Nerve
XII
Hypoglossal

EXAMINATION OF SENSORY SYSTEM

Upper Extremity Lower Extremity Trunk

Type of Sensation
Left Side Right Side Left Side Right Side
Superficial Sensations
Light
Touch Crude
Pressure
Pain
Temperature
Deep Sensations
Propioception
Kinesthesia
Vibration
Cortical Sensations
Tactile Localization
Two Point
Descrimination
Stereognosis
Barognosis
Graphesthesia

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 EXAMINATION OF REFLEXES
Reflexes Right Side Left Side

Superficial Reflexes
1 Abdominal
2 Plantar
Deep Reflexes
1 Biceps
2 Triceps
3 Supinator
4 Knee
5 Ankle
Pathological Reflexes :

EXAMINATION OF MOTOR SYSTEM

Upper Extremity
Region Muscles Right Side Left Side Remarks
Flexors
Extensors
Abductors
Shoulder Adductors
External Rotators
Internal Rotators
Flexors
Elbow Extensors
Pronators
Forearm Supinators
Flexors
Extensors
Wrist Radial Deviators
Ulnar Deviators
Flexors
Extensors
Hand (Thumb) Abductors
Adductors
Flexors
Extensors
Finger Abductors
Adductors

Note: Motor Examination should be done as per the Tone of the Muscles, Hypotonicity (Manual Muscle
Testing), Hypertonicity (Grading for Spasticity)

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 Lower Extremity
Region Muscles Right Side Left Side Remarks
Flexors
Extensors
Abductors
Hip Adductors
External Rotators
Internal Rotators
Flexors
Knee Extensors
Dorsiflexors
Ankle Plantaflexors
Invertors
Foot Evertors
Flexors
Extensors
Toe Abductors
Adductors

Note: Motor Examination should be done as per the Tone of the Muscles, Hypotonicity (Manual Muscle
Testing), Hypertonicity (Grading for Spasticity

MEASUREMENT OF JOINT RANGE OF MOTION

Upper Extremity
Name of Joint Movement Right Side Left Side
AROM PROM AROM PROM
Flexion
Shoulder Extension
Abduction
Adduction
Flexion
Elbow
Extension
Supination
Radioulnar Joint Pronation
Flexion
Extension
Radial Deviation
Wrist Ulnar Deviation
Flexion
Extension
Abduction
Thumb (CMC)
Adduction
Flexion
Extension
Thumb (MCP) Abduction
Adduction
Flexion
Thumb (IP) Extension
* ROM-Range of Motion

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Hand Range of Motion
Right Side Left Side
PIP Joint DIP Joint PIP Joint DIP Joint
Finger Movements AROM PROM AROM PROM AROM PROM AROM PROM
Index Flexion
Finger Extension
Middle Flexion
Finger Extension
Flexion
Ring Finger Extension
Flexion
Little Finger Extension

PIP-Proximal Interpharengeal Joint, DIP-Distal Interpharengeal , AROM-Active Range of Motion, PROM-Passive Range of Motion

Lower Extremity
Joint Movement Right Side Left Side
AROM PROM AROM PROM
Flexion
Hip Extension
Abduction
Adduction
Flexion
Knee
Extension
Dorsiflexion
Ankle
Plnataflexion
Inversion
Subtalar
Eversion

Foot Range of Motion

Right Side Left Side
Movemen PIP DIP PIP DIP
Toe ts AROM PROM AROM PROM AROM PROM AROM PROM
Flexion ---- -- ... ....
Great Toe Extension
Flexion
II Toe Extension
Flexion
III Toe Extension
Flexion
Little Toe Extension

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EXAMINATION OF BALANCE & COORDINATION

EQUILIBRIUM TESTS OF COORDINATION

Test Remarks
Finger to Nose
Finger to Therapist’s Finger
Finger to Finger
Alternate Nose to Finger
Finger Opposition
Mass Grasp
Pronation-Supination
Rebound Test
Tapping (Hand)
Tapping (Foot)
Pointing & Past Pointing
Alternate Heel to Knee, Heel to Toe
Toe to Examiner’s Finger
Heel to Shin
Fixation or Position Holding
Drawing a Circle

NON EQUILLIBRIUM TESTS OF COORDINATION

TEST Remarks
Standing
Standing Feet Together (Narrow BOS)
Tandem Standing
Standing –One Foot
Standing-Functional Reach
Standing Eyes Open(EO) & Eyes Closed (EC)
Standing Laterally Flex Trunk to each side
Tandem Walking
Walking along a Straight Line
Walk Sideways, Backward, Cross Stepping
Marching at One Place
Stop and Start Abruptly on Command While walking
Walk Pivot on Command
Walk in Circle
Walk on Heels or Toes
Walk with Horizontal or Vertical Head Turns
Obstacle walking
Stair climbing with or without using handrail

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 Clinical Tool for Balance screening (Berg Balance scale)
S.No Item Score
1 Sitting to standing
2 Standing unsupported
3 Sitting unsupported
4 Standing to sitting
5 Transfers
6 Standing with eyes closed
7 Standing with feet together
8 Reaching forward with outstretched arm
9 Retrieving object from floor
10 Turning to look behind
11 Turning 360 degrees
12 Placing alternate foot on stool
13 Standing with one foot in front
14 Standing on one foot
Total Score
Berg, Katherine; Wood-Dauphinėe, Sharon; Williams, J.I.; Gayton, David (1989). "Measuring balance in the elderly:
preliminary development of an instrument". Physiotherapy Canada. 41 (6): 304–311.

EXAMINATION OF GAIT AND STATION

Key Points of Observation
 Cadence…………………………………………………………………………………………………
 Stride Length …………………………………………………………………………………………..
 Stride width …………………………………………………………………………………………….
 Arm Swing ……………………………………………………………………………………………...
 Head..........................................................................................................................................................
 Trunk........................................................................................................................................................
 Pelvis.........................................................................................................................................................
 Hip.............................................................................................................................................................
 Knee..........................................................................................................................................................
 Ankle.........................................................................................................................................................
 Foot.......................................................................................................................................................................................

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Examination of Phases

Phase Sub phase Right Side Left Side

Stance Heel Strike
Foot Flat
Midstance
Heel Off
Toe Off
Swing Accelaration
Midswing
Deaccelaration

Other Points
 Pain....................................................................................................................................................
 Base of Support ..............................................................................................................................
 Other Remarks....................................................................................................................................................
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Functional Assessment
 Examination of Activities of Daily Living
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 Assessment of Quality of Life
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(Note: Functional Assessment should be done with the application of with appropriate tools)

Differential Diagnosis
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Provisional Diagnosis
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Problem List
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Primary Goals of Treatment

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Secondary Goals
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Treatment Plan
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Therapist’s Name & Signature

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