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Neurological Examination Form Examiner Name:___________________________ Date:_____________ I. Cranial Nerves: Nerve 1 Olfactory 2. Optic 3. Occulomotor 8. Acoustic 9. Glossopharyngeal 10. Vagus Action Smell Vision Eye movements (superior, medial, inferiorlateral) Eye movement (inferior medial) Face and head sensations, chewing Eye Movement (lateral) Taste (ant 2/3 of tongue), Muscles of facial expression Hearing, balance Taste (post 1/3 tongue), swallowing Swallowing, gag reflex, peristalsis 11. Spinal Accessory 12. Hypoglossal Shoulder movement, head rotation Tongue movements 4. Trochlear 5. Trigeminal 6. Abducens 7. Facial Test Have patient smell something Visual test (read any words) Have pt. look up, towards the nose, then down and out Have pt. look down and in Touch face with an object Have patient look outward Have pt. smile, frown Rub fingers near pt.’s ear Have pt. swallow Initiate gag reflex with tongue depressor Have pt. shrug shoulders Have pt. move tongue in all motions 1 Pt. 1 Pt. 2 Pt. 3 II. Grading Muscle Strength Grade 0 Complete paralysis, no visible movement Grade 1 Trace strength, some visible muscle contraction, with no movement of joint Grade 2 Poor strength, muscle can move the joint, but not against gravity Grade 3 Fair strength, muscle can move against gravity, but not against any examiner resistance Grade 4 Good strength, muscle can move against moderate reistance, but not examiner full resistance Grade 5 Normal strength, muscle can move in full range of motion, against full resistance Muscle Action Grade Pt. 1 Grade Pt. 2 Deltoids Abduction of arms at shoulders Biceps Arm flexion at elbows Triceps Arm extension at elbows Quadriceps Extension of the knee Hamstrings Flexion of the knee III. Deep Tendon Reflexes Grade 0 – no response Grade 1 – minimal response Grade 2 – normal response Grade 3 – slightly hyperactive Grade 4 – hyperactive with clonus/tetany Reflex Action th Biceps Checks 5 cervical nerve: flexion at elbow Brachioradialis Checks 6th cervical nerve: wrist extension Triceps Checks 7th cervical nerve: extension at elbow Patellar Checks 4th lumbar nerve: extension at knee Achilles Checks 1st Sacral nerve: plantar foot flexion 2 Pt. 1 Grade Pt. 3 Pt. 2 Pt. 3 IV. Dermatome Hypoesthesia (decreased sensation) Hyperesthesia (excessive sensation) Normal Anesthesia (loss of sensation) Paresthesia (numbness, tingling, burning sensations) Dermatome Area of the body C5 Upperouter arm (deltoid/biceps region) C6 Thumb side of lower arm, palm side of thumb and index finger C7 Middle finger (both sides) and dorsal (back) side of hand/fingers C8 Palm side of ring and pinky fingers T1 Medial aspect of lower and upper arms L4 Across the knee region L5 Medial side of lower leg and dorsal (top) region of foot S1 Plantar (bottom) region of foot, and posterior aspect of lower leg 3 Pt. 1 Pt. 2 Pt. 3
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