Neurologic Examination
Check normal, circle & describe abnormal Patient:____________________________________ date: ______

CC & significant history: ____________________________________________________ Insurance: ______________________________________ (dd/mm/yr)

__________________________________________________________________________ Date of birth: ____________________________________ M/F
__________________________________________________________________________
Key considerations: □ headache, □ head injury, □ dizziness/vertigo, □ seizures, □ tremors, □ weakness, □ incoordination, □ numbness/tingling,
□ difficulty swallowing, □ difficulty speaking, □ significant past history, □ environmental hazards, □ other: ________________________
□ Refer for secondary consultation: ________________________________________________________________________________________
□ Refer for diagnostic imaging
imaging:: ___________________________________________________________________________________________

Mental Status:: □ WNL Cranial Nerves:: □ WNL

Development (□ good, □ fair, □ poor poor)) I - Olfactory R L VII - Facial R L
Behavior (Alert, lethargic, confusion, speech) Scent #1 Facial expressions
Orientation (Time, person, place & situation) Facial expression #2
Scent #2
Memory/Concentration
II - Optic Normal eye moisture
□ Name president/recent newsworthy events
□ 3 word or place recall at 0 and 5 minutes Visual acuity VIII - Vestibulocochlear
□ (100) - (7) up to five times (93, 86, 79...) Visual fields Rhomberg’s test
□ Spell word backwards Fundiscopic exam Auditory acuity
□ Draw a clock (make the time 12:30) III, IV, VI - Oculomotor, trochlear, Weber
□ Draw overlaping pentagons abducens
Rinne
‘H’ pattern
Convergence IX, X - Glossopharyngeal & Vagus

Nystagmus Gag reflex

Consensual light reflex Elevation of palate

Reflexes:: □ WNL V - Trigeminal XI - Spinal accessory

Lateral jaw deviation Trapezius muscle test

DTR (0-5) R L
Masseter contraction SCM muscle test
Biceps (C5)
Face sensation XII - Hypoglossal
Brachioradialis (C6)
Corneal touch reflex Stick out tongue
Triceps (C7)
Patella (L4)
Cerebellar:: □ WNL Sensory:: □ WNL
Hamstring (L5)
Achilles (S1) R L R L
Rapid finger movement Light touch
Pathologic R L Rapid pro/supination Vibration
Babinski Finger-to-nose/finger Stereognosis
Abdominal Heel down shin Graphesthesia
Hoffman’s Holme’s rebound sign 2-point discrim

*Note presence of clonus Gait/heel-toe walk Position sense

Proprioception
Motor Function: □ WNL Romberg
Sharp/dull
Motor (0-5) R L
Hot/cold
Deltoid (C5, C6) (axillary)
Nerve Tension: □ WNL
Brachioradialis (C5, C6) (radial)
Biceps (C5, C6) (musculocut.) R L
Triceps (C6, C7, C8, T1) (radial) Straight Leg Raise
Wrist flexors (C6, C7) (med./ulnar) Maximal SLR
Wrist extensors (C6, C7, C8) (rad.) Bragard’s
Interossei (C7, C8, T1) (ulnar) Femoral nerve traction
Tib. anterior (L4, L5) (deep per.) Median nerve traction
Extensor hallicus longus (L4, L5, S1) Radial nerve traction
(deep peroneal)
Ulnar nerve traction
Fibularis (peroneus) longus (L5, S1) DDx:
(superficial peroneal) Tinel’s

This form is a comprehensive checklist of examination procedures. Each item should be utilized as a diagnostic option based on the patient’s presenting
symptoms and the clinical discretion of the examiner. Every procedure does not have to be performed on every patient. Some procedures may be Signature: Date:
contraindicated in certain situations. Patient information contained within this form is considered strictly confidential. Reproduction is permitted for personal use,
not for resale or redistribution. www.prohealthsys.com ©2005 by Professional Health Systems Inc. All rights reserved. “Dedicated to Clinical Excellence.”