Form No.

: BMCC-NSD-01-000

Revision No.: 00

Revision Date: 05-10-21

Hospital No.:

Case No.:

Room No.:

NEUROLOGICAL ASSESSMENT MONITORING SHEET

NAME OF PATIENT: _________________________________________ AGE: ______ SEX: ____ ROOM NUMBER: ____

DATE / SHIFT
TIME RECORD ©
IF EYES
SPOTANEOUSLY 4 CLOSED BY
SWELLING
BEST EYE TO SPEECH 3
OPENING TO PAIN 2
RESPONSE
C NONE 1

O ORIENTED 5 RECORD ET
IF
M BEST CONFUSED 4 ENDOTRAC
HEAL TUBE;
A VERBAL WORDS/SPEECH 3 TT IF
RESPONSE TRACHEOS
SOUNDS 2 TROMY
TUBE
NO RESPONSE 1
IS IN PLACE
S OBEYS COMMAND 6 RECORD
BEST LIMB
C BEST LOCALIZES PAIN 5 RESPONSE
A MOTOR WITHDRAW TO PAIN 4
TO
PAINFUL
L RESPONSE FLEXION TO PAIN 3
STIMULI

E
EXTENSION TO PAIN 2

NONE 1

GLASS GOW COMA SCALE

NORMAL POWER RECORD
M ®-Right
O A MILD WEAKNESS (L)- Left
SEPARATEL
V
E
R SEVERE WEAKNESS IF THERE IS
A
M M SPASTIC FLEXION DIFFERENC
E
L N
S SPASTIC EXTENSION E BETWEEN
TWO SIDES
I T NO RESPONSE
/
M S
NORMAL POWER
B T L MILD WEAKNESS
R
S E E SEVERE WEAKNESS
N G SPASTIC FLEXION
G
T S SPASTIC EXTENSION
H NO RESPONSE
SIZE RECORD
RIGHT (B)- Brisk
EYE REACTION (S)-Sluggish
(F)- Fixed
SIZE
LEFT
EYE REACTION
2mm 3mm 4mm 5mm 6mm 6mm 8mm 9mm