Neurology
Medical History, PE & Neurologic Exam Guide
Name of Student: __________________________ Ward: __________ Bed# ____ Date/Time of Interview: ___________________
PATIENT PROFILE
I. Life History
Name of Patient: ____________________________________
Sex: _____ Age: _____ Birth date: ____________________
Place of residence: __________________________________
__________________________________________________
Place of birth: ______________________________________
Race: __________________ Religion: __________________
Educational attainment: ______________________________
Socioeconomic status: _______________________________
Family composition: _________________________________
Patient’s place in the family: ___________________________
Living environment
Description of community: __________________________
________________________________________________
Density of population in the neighborhood: ____________
________________________________________________
Basic facilities: ___________________________________
House structure: __________________________________
No. of persons living in the place of habitat: ____________
State of hygiene: __________________________________
Access to potable water: ___________________________
Waste & garbage disposal: __________________________
Electricity: _______________________________________
Hobbies/Interests: __________________________________
__________________________________________________
II. Marital Status
___ Single ___ Widowed ___ Separated
___ Married ___ Divorced ___ Others: ___________
History/Compatibility/Adjustment: _____________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
III. Occupation & Employment History
Present Occupation: _________________________________
Previous Occupation: ________________________________
Presence of Occupational Hazards: _____________________
__________________________________________________
Adjustment to Working Situations: _____________________
__________________________________________________
IV. Financial Status/Source of Medical Care:
__________________________________________________
__________________________________________________
V. Personality Type/Reaction to Environment:
__________________________________________________
__________________________________________________
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VI. Habits/Description of Average Day:
Dietary/Eating Habits: ________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Sleeping Habits: _____________________________________
__________________________________________________
Exercise: __________________________________________
__________________________________________________
Use of Tobacco: Yes ___ No ___ Pack Years: ____________
Quitted ___ Since when ________________
Alcohol Intake: Yes ___ No ___ Quitted ___ Since when _____
Type: ___________________________________________
Quantity/Duration: ________________________________
Caffeine Intake: _____________________________________
Illicit Drug Use: _____________________________________
VII. Current Medications
Drug Dosage Frequency Compliance
& duration
of intake
Date of Admission: __________________________________
SOURCE/RELIABILITY: ________________________________
CHIEF COMPLAINT/S
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
HISTORY OF THE PRESENT ILLNESS
I. Onset
Date of onset: ______________________________________
Manner of onset: ___ Gradual ___ Acute
Precipitating/Predisposing factors: ______________________ PAST HEALTH MAINTENANCE HISTORY
__________________________________________________ I. Childhood Diseases
__________________________________________________ ___ Measles ___ Polio
__________________________________________________ ___ Chickenpox ___ Diphtheria/Pertussis/Tetanus
__________________________________________________ ___ Mumps ___ Rheumatic fever
II. Characteristics ___ Rubella ___ Typhoid fever
Character (Quantity, Quality, Consistency, Appearance): ___ Varicella ___ Dengue fever
__________________________________________________ Others: ____________________________________________
__________________________________________________
__________________________________________________ II. Allergies
__________________________________________________ __________________________________________________
Location/Radiation: __________________________________ __________________________________________________
Intensity/Severity (Pain Scale): _________________________
Timing: III. Surgeries
___ Continuous ___ Intermittent Date Indication Type of Operation
___ Rhythmic ___ Remittent
Aggravating/Relieving Factors: _________________________
__________________________________________________
__________________________________________________
__________________________________________________
Associated Symptoms: _______________________________
__________________________________________________
__________________________________________________
__________________________________________________
IV. Immunizations
III. Course since Onset ___ BCG ___ OPV
Incidence: ___ DPT ___ Measles
___ Single acute attack ___ Recurrent acute attack ___ Hepatitis B ___ Tetanus toxoid
___ Daily occurrences ___ Periodic occurrences ___ HiB ___ Pneumococcal
___ Continuous chronic episode ___ Varicella ___ Typhoid fever
___ Rotavirus ___ Cholera
IV. Effects of Therapy ___ Rabies ___ Others: __________________
Alleviation due to therapy? Yes ___ No ___
Has drug suppressed or masked symptom/s? Yes ___ No ___ V. Hospitalizations
Toxic effects producing other symptoms: ________________ Date Hospital Diagnosis Procedures
__________________________________________________ Done
Appropriate dosage? Yes ___ No ___
Duration of treatment: _______________________________
Others ____________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

V. Progress
What happened to the symptom/s during the total duration
of illness?
___ Better ___ Worse ___ Unchanged ___ Disappeared VI. Major Illnesses
Notes _____________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
__________________________________________________
__________________________________________________ VII. Accidents
__________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
__________________________________________________ __________________________________________________
__________________________________________________
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VIII. Pregnancies/Deliveries Familial incidences of:
G ___ P ___ Term ___ Premature ___ Living ___ Abortion ___ ___ Diabetes Mellitus ___ Hypertension
___ Cardiovascular Disease ___ Cerebrovascular Disease
# Date of AOG Manner Complications Sex/ ___ Allergies ___ Cancer
Delivery of Condition ___ Mental Illness ___ Others: _____________
Delivery of Baby
ADDENDUM: SEXUAL HISTORY
Age at first coitus: _____ y/o
Date of last sexual intercourse: ________________________
Sexual orientation/preference: ________________________
No. of sexual partners
in the last 6 months __________________________
in the last 5 yrs ______________________________
in the patient’s lifetime _______________________
History of sexually transmitted infections: ________________
__________________________________________________
Others: ____________________________________________ __________________________________________________
__________________________________________________ Routine contraceptive use: Yes ___ No ___
__________________________________________________ Natural Method:
___ Withdrawal
FAMILY HISTORY Rhythm Method:
___ Calendar
Grandparent Age Health Status Cause of Death/ ___ Basal Body Temperature
Age at Death ___ Cervical Mucus
___ Symptothermal
___ Lactation Amenorrhea Method (LAM)
Artificial Method:
___ Chemical barriers (spermicides,
vaginal sponge)
Physical barriers:
___ Diaphragm
___ Cervical cap
Parent Age Health Status Cause of Death/ ___ Condom (male/female)
Age at Death ___ Oral contraceptive pills
___ Injectables
___ Subdermal implants
___ Morning-after pill
___ Contraceptive patch
___ Intrauterine device (IUD)
Permanent Method:
Sibling Sex Age Health Cause of Death/ ___ Vasectomy
Status Age at Death ___ Tubal ligation

Similar illness/symptom in the family: ___________________
__________________________________________________
__________________________________________________
__________________________________________________
ADDITIONAL NOTES
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

3
 REVIEW OF SYSTEMS

Instructions: Write N if findings are negative/normal. Place a

check if findings are positive/abnormal then describe in space
provided. DESCRIPTION

I. General
___ Fever ___ Sweating ___ Weakness
___ Fatigue ___ Weight Loss

II. Skin
___ Color ___ Texture
___ Itching ___ Rashes
Changes in: ___ Hair ___ Nails

III. Eyes
___ Visual Impairment ___ Double Vision
___ Redness ___ Discharge
___ Tearing ___ Trauma
___ Pain

IV. Ears
___ Hearing Loss ___ Discharge
___ Otalgia ___ Tinnitus

V. Nose, Throat, Mouth

___ Nasal Obstruction ___ Change in voice
___ Discharge ___ Neck mass
___ Abnormal olfaction/anosmia ___ Toothache
___ Epistaxis ___ Dental caries
___ Frequent colds/cough ___ Gum bleeding
___ Dysphagia ___ Ulceration
___ Odynophagia ___ Congenital deformity

VI. Respiratory
___ Cough/Sputum ___ PTB exposure
___ Difficulty of breathing ___ Hemoptysis
___ Wheezing (asthma)

VII. Cardiovascular
___ Palpitation ___ Hypertension
___ Syncope ___ Orthopnea
___ Chest pain ___ Dyspnea
___ Edema

VIII. Gastrointestinal
___ Dysphagia ___ Heartburn
___ Nausea ___ Hematemesis
___ Vomiting ___ Fatty food intolerance
___ Appetite ___ Stool frequency/
___ Abdominal pain character
___ Melena ___ Hemorrhoids
___ Jaundice ___ Abdominal distention
___ Bleeding ___ Hernia
___ Indigestion

4
IX. Urinary DESCRIPTION
___ Pain ___ Stones
___ Volume ___ Infection
___ Retention ___ Hesitancy
___ Bleeding ___ Urgency
___ Stream ___ Change in color
___ Polyuria ___ Frequency
___ Nocturia ___ Dribbling

X. Genitoreproductive
Male: ___ Discharge ___ Libido
___ Pain ___ Sexual difficulties
Female: Menarche _______ y/o
LMP ______________
PMP ______________
Menses: ___ Regular Duration: ________________
Amount: ____________________________
___ Abnormal vaginal bleeding
___ Dysmenorrhea/pelvic pain
___ Post-coital bleeding
___ Discharge ___ PID
___ Contraceptive use # of Pregnancies: _____
Complications: _________________________________
Live Births: _____ Heaviest baby: _____ lbs
Menopause age: _____
___ Post-menopausal bleeding

XI. Breast
___ Nipples ___ Pain
___ Lump ___ Discharge

XII. Extremities
___ Cyanosis ___ Varicosity
___ Clubbing ___ Ulcers
___ Edema ___ Claudication

XIII. Hematopoietic System

___ Excessive bleeding/bruising
___ Anemia
___ Pica

XIV. Nervous System

___ Headache ___ Dizziness/vertigo
___ Tremor ___ Head trauma
___ Fainting spells ___ Sensory perversions
___ Seizures

XV. Musculoskeletal System

___ Joint stiffness ___ Swelling
___ Pain ___ Muscle weakness

XVI. Endocrine System

___ Heat/cold intolerance ___ DM indicators
___ Thyroid problems ___ Neck surgery/irradiation

XVII. Psychiatric
___ Mood swings ___ Anxiety
___ Behavioral changes ___ Depression

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 PHYSICAL EXAMINATION

I. Vital Signs DESCRIPTION

Temperature = ______ °C ___ Oral ___ Tympanic
___ Axillary ___ Rectal

BP = ________ mm Hg ___Sitting ___ Lying ___ Standing

PR = ________ bpm ___ Regular ___ Irregular

HR = ________ bpm ___ Regular ___ Irregular

RR = ________/min Depth: ________________________________

___ Normal rhythm ___ Cheyne-Stokes
___ Bradypnea ___ Obstructive
II. General Survey ___ Tachypnea ___ Hyperpnea, hyperventilation
Apparent state of health: ___ Sighing respiration ___ Ataxic
___ Acutely Ill ___ Frail
___ Chronically Ill ___ Fit
___ Robust

Level of consciousness: NOTES (from Bates’):

___ Alert ___ Stuporous Lethargic – patient appears drowsy but opens the eyes and looks
___ Lethargic/Drowsy ___ Comatose at you, responds to questions, and then falls asleep
___ Obtunded Obtunded – opens the eyes and looks at you, but responds
slowly and is somewhat confused. Alertness and interest in the
Signs of distress: environment are decreased.
___ Cardiorespiratory Distress ___ Anxiety Stuporous – arouses from sleep only after painful stimuli. Verbal
___ Pain ___ Depression responses are slow or even absent. The patient lapses into an
unresponsive state when the stimulation ceases. There is
Dress, grooming, personal hygiene: minimal awareness of self or the environment.
___ Appropriate ___ Inappropriate Comatose – patient remains unarousable with eyes closed.
There is no evident response to inner need or external stimuli.
Facial expression:
___ Alert, attentive to questions
___ Makes eye contact
___ Appears dull, drowsy, stares into space
___ Confused
___ Angry
___ Impatient
___ Restless

Coherence & orientation:

___ Coherent
___ Incoherent
___ Oriented to time, person and place
___ Disoriented to time, person and place

Odors of body/breath: __________________________________

Posture, gait, motor activity:

___ Coordinated ___ Uncoordinated
___ Unable to walk alone ___ Walks w/ assistive devices

Height: _____________ Waist-Hip Ratio: _________

Weight: ____________ kg/lbs Body Mass Index: ________

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III. Skin & Hair DESCRIPTION
Color: ___ Redness/flushing ___ Pallor
___ Increased pigmentation ___ Cyanosis
___ Decreased pigmentation ___ Jaundice
Texture: ___ Rough/Dry ___ Smooth
Moisture: ___ Dry ___ Wet/clammy ___ Oily
Turgor: ___ Good ___ Fair ___ Poor
Temperature: ___ Symmetrical ___ Non-symmetrical
___ Rashes (describe)
___ Lesions: ___ Primary ___ Secondary Type: ________________________________________________
Color: _______________________________________________
Size: _________________________________________________
Pattern: ___ Linear ___ Annular/Ring-like
___ Iris/target ___ Grouped
___ Herpetiform ___ Zosteriform
Nails: ___ Oil spots ___ Loosening ___ Lesions Shape: _______________________________________________
___ Crumbling ___ Pitting Distribution: ___ Localized ___ Generalized
Hair: ___ Coarse ___ Dry ___ Smooth and soft Location: _____________________________________________
___ Alopecia: ___ Diffuse ___ Patchy ___ Total Effect of Pressure: ___ Blanching ___ Non-blanching

IV. Chest & Lungs

Inspiration-Expiration Ratio: ______ : ______
Chest shape: AP/L Ratio: __________
___ Deformities: ___ Barrel
___ Funnel
___ Pigeon
___ Traumatic flail chest
___ Thoracic kyphoscoliosis
Signs of distress: ___ Alar flaring
___ Purse lip breathing
___ Intercostal retractions
___ Splinting
___ Use of accessory muscles
Chest expansion: ___ Symmetrical ___ Lag at R/L
Palpation: ___ Tenderness ___ Masses
Tactile fremitus: ___ Symmetrical ___ Decreased at ________
Note on percussion: ___ Flat ___ Hyperresonant
___ Dull ___ Tympanic
___ Resonant
Breath sounds: ___ Symmetrical ___ Decreased at _____ Location of breath sounds: _______________________________
___ Vesicular ___ Bronchial __________________________________________________
___ Bronchovesicular ___ Tracheal __________________________________________________
Adventitious breath sounds:
___ Crackles ___ Stridor
___ Wheezes ___ Pleural friction rub
___ Rhonchi ___ Mediastinal crunch

V. Cardiovascular
Periorbital region: ___ Edema/Swelling ___ Sunken
Conjunctiva: ___ Pinkish ___ Pale
Lips: ___ Pallor ___ Cyanosis
___ Dry/Cracked ___ Lesions
Tongue size: ___ Enlarged
Gums: ___ Pinkish ___ Pallor
___ Bleeding ___ Tenderness
Buccal mucosa: ___ Pinkish ___ Pale
Pharynx: ___ Pinkish ___ Reddish ___ Pale
Jugular venous pulse: ____ cm w/ head of bed elevated at ____ °
Carotid Artery: ___ Thrills ___ Bruits
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 DESCRIPTION
Precordium: ___ Flat ___ Adynamic
___ Bulging ___ Dynamic
___ Tenderness ___ Heaves
___ Thrills
PMI at: ______________________________________________
Heart Sounds: ___ Distinct ___ Faint
S1 _____ S2 at the base
S1 _____ S2 at the apex
Extra heart sounds: ___ S3 ___ S4
___ Murmurs (Grade: _____)
Nails: ___ Cyanosis ___ Pallor
___ Clubbing ___ Spooning
Capillary refill time: _____ secs
___ Edema of the extremities: ___ Bilateral
___ Unilateral
___ Pitting
___ Non-pitting
Peripheral pulses: ___ Symmetrical ___ Regular
___ Asymmetrical ___ Irregular
___ Weak ___ Strong
___ Faint ___ Bounding
___ Absent Grade: _________

VI. Gastrointestinal/Abdominal
Skin: ___Scars ___ Striae
___ Dilated veins ___ Rashes & lesions
Umbilicus: ___ Sunken ___ Bulging
___ Inflammation
Contour: ___ Flat ___ Bulging of flanks
___ Rounded ___ Symmetrical
___ Protuberant ___ Asymmetrical
___ Scaphoid ___ Visible organs/masses Characteristics of mass
Location: _____________________________________________
___ Visible peristalsis ___ Increased pulsations Size: _________________________________________________
Bowel sounds: _____ /min ___ Borborygmi Shape: _______________________________________________
___ Increased ___ Abdominal bruits Consistency: __________________________________________
___ Decreased ___ Friction rub Tenderness: __________________________________________
___ Absent ___ Venous hum Pulsations: ___________________________________________
Note on Percussion: ___ Hypertympanic ___ Tympanic Mobility with respiration or with the examining hand: _________
___ Dullness at _____________________ _____________________________________________________
___ Shifting dullness

___ Voluntary guarding ___ Direct tenderness

___ Muscle rigidity ___ Rebound tenderness
___ Fluid wave ___ Rovsing’s Sign
___ Ballotment ___ Obturator Sign
___ Psoas Sign ___ Murphy’s Sign

LIVER:
Liver size: ________________ cm/in
Tenderness on percussion: ___ Yes ___ No
Tenderness on palpation: ___ Yes ___ No
___ Soft, sharp, regular edge with smooth surface
___ Firm/hard, blunt/rounding of edge, irregular contour

SPLEEN:
Dullness on percussion: ___ Yes ___ No
___ Splenic percussion sign
8
___ Non-palpable ___ Palpable DESCRIPTION
___ Non-tender ___ Tender

AORTA:
Aortic pulsations: ___ Yes ___ No

VII. Genitourinary
KIDNEYS:
___ Non-palpable ___ Palpable
___ CVA tenderness

BLADDER:
___ Non-palpable ___ Palpable
___ Non-tender ___ Tender
Dullness on percussion: ___ Yes ___ No

Male
Skin: ___ Redness ___ Discoloration
___ Papules ___ Pustules
___ Macules ___ Vesicles
___ Ulcers ___ Nodules
___ Plaques ___ Excoriations
___ Others: ______________________________________
Pubic Hair: Distribution: _________________________________
___ Nits ___ Lice
Prepuce: ___ Phimosis ___ Paraphimosis ___ Smegma
Penis: ___ Discharge ___ Tenderness
___ Ulcers ___ Scars
___ Swelling ___ Nodules
___ Induration
Urethral Meatus: ___ Hypospadia ___ Epispadia
Scrotum: ___ Equal ___ Unequal
___ Edema at R/L ___ Enlargement at R/L
___ Tenderness ___ Undescended at R/L
___ Rashes ___ Nodules
___ Veins ___ Lumps
___ Epidermoid Cysts ___ Bulging
Prostate: ___ Smooth ___ Firm
___ Rubbery ___ Non-tender
___ Swelling ___ Tender
___ Bogginess ___ Warm
___ Nodules
Bulging: ___ External Inguinal Ring ___ Internal Inguinal Ring
___ Anterior thigh (femoral canal)

Female
Mons Pubis: ___ Excoriations ___ Itchiness
___ Redness ___ Papules
___ Macules ___ Pustules
___ Plaques ___ Vesicles
___ Ulcers ___ Nodules
___ Others: ________________________________
Pubic Hair: Distribution: _________________________________
___ Nits ___ Lice
Clitoris: ___ Enlargement
Urethral Meatus: ___ Caruncle ___ Prolapse

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Labia: ___ Symmetrical ___ Asymmetrical DESCRIPTION
___ Tenderness ___ Discoloration
___ Redness ___ Edema/Swelling
Hymen: ___ Intact ___ Imperforated
Vaginal Introitus: ___ Inflammation ___ Swelling
___ Vesicles ___ Pustules
___ Ulcerations ___ Nodules
___ Others: ____________________________
___ Discharge: ___Serous ___ Purulent
___ Mucoid ___ Foul-smelling
___ Whitish, curd-like ___ Others

VIII. Musculoskeletal Location Laterality

___ Asymmetry ___ Contractures ___ Temporomandibular joints (TMJ)
___ Swelling ___ Decreased ROM ___ Shoulder girdle (sternoclavicular,
___ Tenderness ___ Palpable crepitus/clicking acromioclavicular, glenohumeral joints)
___ Redness ___ Deformities ___ Wrist joints (radiocarpal, distal
___ Warmth ___ Displacement radioulnar, intercarpal joints)
___ Thickness ___ Deviations ___ Hand joints (MCPs, PIPs, DIPs)
___ Nodules ___ Ballottement ___ Anatomical snuffbox
___ Spinous processes
___ Facet joints
___ Sacroiliac joints
___ Knee joints (tibiofemoral, patellofemoral joints)
___ Suprapatellar pouch
___ Ankle joints (tibiotalar, subtalar joints)
___ Transverse tarsal & metatarsophalangeal joints
___ Bursae (specify: _______________________)
___ Biceps tendon
___ Patellar tendon
___ Achilles tendon

Decreased ROM on:

___ Flexion ___ Abduction ___ Internal rotation
___ Extension ___ Adduction ___ External rotation
___ Pronation ___ Opposition ___ Inversion
___ Supination ___ Lateral bending ___ Eversion

___ Neer’s Impingement Sign ___ Balloon Sign

___ Hawkin’s Impingement Sign ___ McMurray Sign
___ Drop-arm Sign ___ Valgus Stress
___ Yergason Sign ___ Varus Stress
___ Tinel’s Sign ___ Trigger finger
___ Phalen’s Sign ___ Anterior Drawer Sign
___ Bulge Sign ___ Posterior Drawer Sign
___ Beevor’s Sign ___ Lasegue’s Sign
___ Pes planus ___ Pes cavus

Spine: ___ Erect position of the head

___ Smooth, coordinated neck movement
___ Neck stiffness
___ Head & neck in midline
___ Lateral deviation & rotation of the head
___ Equal shoulder heights
___ Shoulder tilt
___ Pelvic tilt
___ Deviation to the R/L
___ Abnormal curvatures: ___ Gibbus ___ Lordosis
___ Kyphosis ___ Others
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 NEUROLOGIC EXAMINATION

I. Mental Status

Patient’s Name: ________________________________ Examiner: ___________________________ Date: _________________

Instructions: Ask the questions in the order listed. Score one point for each correct response within each question or activity.

Maximum Score Patient’s Score Questions

5 Orientation
“What is the year? Season? Date? Day of the week? Month?”
5 “Where are we now: State? Country? Town/city? Hospital? Floor?”
3 Registration
The examiner names three unrelated objects clearly and slowly, then asks the patient to name all
three of them. The patient’s response is used for scoring. The examiner repeats them until
patient learns all of them, if possible. Number of trials: ________________
5 Attention & Calculation
“I would like you to count backward from 100 by sevens.” (93, 86, 79, 72, 65….) Stop after five
answers.
Alternative: “Spell WORLD backwards.” (D-L-R-O-W)
3 Recall
“Earlier I told you the names of three things. Can you tell me what those were?”
2 Language & Praxis
Show the patient two simple objects, such as wristwatch and a pencil, and ask the patient to
name them.
1 “Repeat the phrase: ‘No ifs, ands, or buts.”
3 “Take the paper in your right hand, fold it in half, and put it on the floor.” (The examiner gives the
patient a piece of blank paper.)
1 “Please read this and do what it says.” (Written instruction is “Close your eyes.”)
1 “Make up and write a sentence about anything.” (This sentence must contain a noun and a verb.)
1 “Please copy this picture.” (The examiner gives the patient a blank piece of paper and asks
him/her to draw the symbol below. All 10 angles must be present and two must intersect.)

30 TOTAL
*Adapted from Rovner & Folstein, 1987

DESCRIPTION
II. Cranial Nerves
CN I (Olfactory): ___ Intact
___ Anosmia (unilateral/bilateral)
CN II (Optic):
Visual acuity:
VA (w/correction) OD ________
OS ________
(w/out correction) OD ________
OS ________
___ Counting fingers at _____ ft
___ Hand movement at ___ RUQ ___ LUQ
___ RLQ ___ LLQ
___ R temporal ___ L temporal
___ R nasal ___ L nasal
___ Light projection at _________________ quadrant/s
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 DESCRIPTION
___ Light perception: ___ Vague ___ Erratic Confrontation Field Diagram:
Visual fields: (see column 2: Confrontation field diagram)
Fundoscopy: T N T
Media: ___ Clear ___ Hazy
Disc borders: ___ Distinct ___ Blurred
*Cup disc ratio = _____ : _____
**Arteriole-venule ratio (AVR) = _____ : _____ LE RE
AV Crossing: ___ Normal ___ AV Nicking
___ Banking ___ Tapering and banking
Red orange reflex: ___ Positive ___ Negative
___ Hemorrhages ___ Exudates *Normal Cup-disc ratio = 0.4 – 0.5
___ Papilledema ___ Glaucomatous cupping **Normal Arteriole-venule ratio (AVR) = 2:3
___ Optic atrophy ___ Microaneurysms
___ Neovascularization ___ Hypertensive retinopathy
___ Macular Star ___ Diabetic retinopathy
___ Drusen ___ Healed chorioretinitis
Reflexes: ___ Optic blink reflex ___ Red orange reflex
CN III, IV, VI (Oculomotor, Trochlear, Abducens):
Primary gaze: ___ In midline ___ Disconjugate
Eye Movements: ___ Esotropia ___ Strabismus
___ Exotropia ___ Diplopia
Convergence: ___ Equal ___ Unequal
Pupil size: ___ Equal ___ Unequal
R = _____ mm L = _____ mm
Pupillary response to light: *Pain, temperature, light touch
___ Reactive ___ Parallel
___ Brisk ___ Sluggish
___ Fixed ___ Swinging light reflex
Accommodation: ___ Responsive ___ Non-responsive
CN V (Trigeminal):
Reflexes: ___ Jaw jerk reflex ___ Corneal reflex
*Facial sensation: ___ Intact ___ Impaired
Motor function: ___ Intact ___ Paralysis at R/L
___ Weakness at R/L
CN VII (Facial):
Motor function: ___ Intact ___ Weakness at R/L
___ Symmetrical ___ Paralysis at R/L
___ Asymmetrical
Taste sensation (anterior 2/3): ___ Intact ___ Impaired
CN VIII (Vestibulocochlear):
Rubbed hair/fingers heard at ____ cm (AD) & ____ cm (AS)
Weber’s Test: ___ In midline ___ Lateralizes to R/L ear
Rinne’s Test: ___ : ___ (air conduction to bone conduction)
CN IX & X (Glossopharyngeal & Vagus):
Gag reflex: ___ Intact ___ Absent
Uvula: ___ In midline ___ Deviated to R/L
Palate: ___ Intact ___ Weakness on the R/L
Taste sensation (posterior 1/3): ___ Intact ___ Impaired
Speech: ___ Hoarseness ___ Nasal twang
Swallowing: ___ Coordinated ___ Impaired
CN XI (Spinal Accessory):
SCM: ___ Intact ___ Weakness at R/L ___ Paralysis at R/L
Trapezius: ___ Intact ___ Paralysis at R/L
___ Weakness at R/L
CN XII (Hypoglossal):
Tongue: ___ In midline ___ Deviation to R/L
___ Atrophy ___ Fasciculations

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III. Motor Function DESCRIPTION
Involuntary movements: ___ Tics ___ Choreoathetosis
___ Tremors ___ Fasciculations NUMERICAL SCALE TO RECORD MUSCLE STRENGTH
Strength: _____/5 located at (see column 2 – Muscle Groups) (British Medical Research Council)
___ Tenderness ___ Pronator drift ___ Gowers’ Sign Score Description
Tone: ___ Normal ___ Flaccid ___ Spastic ___ Rigidity 5 Normal strength
Bulk: ___ Atrophy ___ Hypertrophy ___ Pseudohypertrophy 4 Moves joint through full range against resistance
greater than gravity but examiner can overcome
the action (make a percentage estimate of
strength to compensate for broad range of this
number)
3 Moves part full range against gravity but not
against any resistance
2 Moves part only when positioned to eliminate
gravity
1 Only flicker of contraction of muscle but cannot
move joint
0 Complete paralysis
*Compare proximal/distal, right/left, upper/lower
from De Myer’s Neurologic Examination 6th Ed, pg. 248

Muscle Groups Strength

___ Muscles of mastication (masseter,
temporal, pterygoid ms.)
___ Axioscapular group (trapezius, rhomboids,
serratus anterior, levator scapulae)
___ Axiohumeral group (pectoralis major &
minor, latissimus dorsi)
___ Scapulohumeral/SITS ms.
___ Biceps ms.
___ Triceps ms.
___ Thenar ms.
___ Hypothenar ms.
IV. Sensory function ___ Paravertebral ms.
Crude ___ Iliopsoas ms.
Touch: ___ Intact & symmetrical ___ Gluteal ms.
___ Impaired at _____________________________ ___ Quadriceps femoris
Pain: ___ Intact & symmetrical ___ Hamstring ms.
___ Impaired at ______________________________ ___ Gastrocnemius ms.
Temperature: ___ Intact & symmetrical ___ Soleus ms.
___ Impaired at ______________________ ___ Plantar and dorsiflexor ms.
Vibration: ___ Intact & symmetrical
___ Impaired at _________________________ Muscle weakness on:
Joint position sense: ___ Intact & symmetrical ___ Flexion ___ Abduction ___ Internal rotation
___ Impaired at _________________ ___ Extension ___ Adduction ___ External rotation
Romberg’s Test: ___ Positive ___ Negative ___ Pronation ___ Opposition ___ Inversion
___ Supination ___ Lateral bending ___ Eversion
Cortical
Graphesthesia: ___ Intact ___ Impaired at R/L palm
Stereognosis: ___ Intact ___ Impaired at R/L hand
Two-point discrimination: R _____ cm L _____ cm Two-point discrimination:
Bilateral simultaneous stimulation: ___ Intact Fingertips = 2 – 4 mm
___ Extinction at R/L Dorsum of fingers = 4 – 6 mm
Point localization: ___ Intact ___ Extinction at R/L side Palm = 8 – 12 mm
Dorsum of hand = 20 – 30 mm
V. Cerebellar
***Coordination: ___ Intact ___ Dysmetria ***Finger-to nose, alternating pronation-supination, finger
___ Dysdiadochokinesia tapping, heel-to-shin, tibial tapping
___ Nystagmus ___ Tremors (at rest/intention)
13
 Stance: ___ Wide base Feet _____ cm apart DESCRIPTION
**Gait: ___ Staggering ___ Shuffling **Natural, tandem walking
___ Cerebellar ataxia ___ Waddling
___ Drunken/Reeling ___ Toppling
___ Sensory ataxia ___ Frontal lobe disorder
___ Steppage/Equine ___ Parkinsonian gait
___ Marche a petit pas ___ Hemiplegic/Paraplegia
___ Hysterical ___ Choreoathetotic/Dystonic

VI. Reflexes
Superficial/Primitive Reflexes
___ Snout ___ Rooting
___ Sucking ___ Palmar grasp
___ Plantar grasp ___ Babinski
___ Abdominal ___ Cremasteric

Deep Tendon Reflexes (grade using diagram on column 2): Reflexes (grade):
Biceps Triceps
Brachioradialis Knee
Ankle jerk
___ Hoffman’s ___ Clonus

SCALE FOR GRADING REFLEXES

4+ Very brisk, hyperactive, with clonus (rhythmic
oscillations between flexion and extension
3+ Brisker than average; possibly but not necessarily
indicative of disease
2+ Average; normal
1+ Somewhat diminished; low normal
0 No response
from Bates’ Guide to Physical Examination 10th Ed, pg. 696
VII. Meninges
___ Kernig’s Sign ___ Brudzinski’s Sign

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