DATE          TIME (24hr)          Examiner:          Subject Code: 

Cranial Nerves I-XII:

1. Olfactory:
       Normal (detection and identification of 3 odors)
       Abnormal
        

2. Optic:
        Pupils:     PERRLA;     size asymmetry:     light reaction asymmetry
Visual acuity: Left 20/XX Right 20/xx
Visual Field:      intact     abnormal

3,4,6. Extraocular movement:
Normal
Nystagmus: absent present OD OS OU

5. Facial sensation:
Ptosis: absent present OD OS OU
Face sensation: normal reduced left right
Face at rest: symmetrical drooped ? left right
Face Palsy: (0-3 scale, Modified NIH Stroke Scale)
none (0) minor (1) partial (2) complete (3)

7. Facial strength:

8. Hearing:
normal reduced left right

9 - 12:
Uvula/palate: midline deviate to left deviate to right
Shoulder shrug: intact impaired? left right
Tongue: midline deviate to left deviate to right

Motor:
Muscle atrophy: absent present ? LUE RUE LLE RLE
Tone: normal abnormal (check below)
increased ? LUE RUE LLE RLE
reduced ? LUE RUE LLE RLE

Motor strength: (0-5 scale)
normal (5) weakness LUE RUE LLE RLE
Pattern of weakness: proximal distal localized diffuse
Severity of weakness: slight (4) mild (3) moderate (2) severe (1) plegic (0)
Gower's sign: absent present

Reflexes:
Deep Tendon Reflex (0-4 scale):
LUE: biceps triceps brachioradialis
RUE: biceps triceps brachioradialis
LLE: knee ankle
RLE: knee ankle

Clonus: absent present left right

Plantar response, L: flexor extensor
Plantar response, R: flexor extensor

Sensory Exam:
(0-2 scale, Modified NIH Stroke Scale)
Sensory loss location absent present LUE RUE LLE RLE
Severity of loss: none (0) mild (1) severe (2)

Cerebellar:
Tremor at rest: (0-4 scale, motor exam, Unified Parkinson's Disease Rating Scale)
Severity of tremor: none(0) slight-mild (1) mild-mod (2) mod-severe (3) marked (4)
Action/postural tremor: (0-4 scale, motor exam, Unified Parkinson's Disease Rating Scale)
Severity of tremor: none (0) slight-mild (1) mild-mod (2) mod-severe (3) marked (4)
Rigidity: (0-4 scale in "Severity of rigidity", motor exam, Unified Parkinson's Disease Rating Scale)
Severity of rigidity: none (0) slight (1) mild-mod (2) mod-severe (3) severe (4)
Rapid Alternating Movement: (0-4 scale, motor exam, Unified Parkinson's Disease Rating Scale)
Finger tapping, LEFT: normal (0) abnormal, check below
mild (1) moderate (2) severe (3) barely moving (4)
Finger tapping, RIGHT: normal (0) abnormal, check below
mild (1) moderate (2) severe (3) barely moving (4)
Hand pronate/supinate: normal (0) abnormal, check below
(worst hand) mild (1) moderate (2) severe (3) barely moving (4)
Foot tapping, LEFT: ? normal (0) ? abnormal, check below
mild (1) moderate (2) severe (3) barely moving (4)
Foot tapping, RIGHT: normal (0) abnormal, check below
mild (1) moderate (2) severe (3) barely moving (4)
Coordination: (0-4 scale, Kinetic function, #8, #10, International Cooperative Ataxia Rating Scale)
Finger to nose, LEFT: normal (0) abnormal, check below
mild (1) moderate (2) severe (3) unable to reach (4)
Finger to nose, RIGHT: normal (0) abnormal, check below
mild (1) moderate (2) severe (3) unable to reach (4)
Heel to shin, LEFT: ? normal (0) ? abnormal, check below
mild (1) moderate (2) severe (3) extreme (4)
Heel to shin, RIGHT: normal (0) abnormal, check below
mild (1) moderate (2) severe (3) extreme (4)
Posture: (0-4 scale, posture and gait disturbance, International Cooperative Ataxia Rating Scale)
Body sway, eyes open normal (0) mild (1) moderate (2) severe (3) falling (4)
Body sway, eyes close normal (0) mild (1) moderate (2) severe (3) falling (4)

GAIT: (0-4 scale, ADL- walking; Motor exam-gait, Unified Parkinson's Disease Rating Scale)
Causal gait: normal (0) mild (1) moderate (2) severe (3) unable (4)
Heel walking: normal (0) mild (1) moderate (2) severe (3) unable (4)
Toe walking: normal (0) mild (1) moderate (2) severe (3) unable (4)
Tandem gait: normal (0) mild (1) moderate (2) severe (3) unable (4)
Language: normal receptive aphasia expressive aphasia unable to
Speech: (0-4 scale, motor exam, Unified Parkinson's Disease Rating Scale)
normal (0) abnormal, check below
mild (1) slurred, mod (2) hard to understand (3) unintelligible (4)
Tender Points: absent present total number