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Neurological Exam Form Template

Streamline Your Neurological Assessments with Ease

Conducting a thorough neurological exam is crucial, but recording findings can often feel overwhelming. This neurological exam template is designed for healthcare professionals seeking a reliable way to evaluate and document patient assessments quickly and effectively. With this template, you can streamline your examination process, ensure accurate documentation, and provide comprehensive care for your patients, all while maintaining compliance with healthcare standards. Easily customize fields to match your practice's needs, boost your efficiency, and ultimately improve patient outcomes. Explore the template now to see how it can help you.

Full legal name
Date of birth
Medical record number or patient ID
Primary phone number
Email address
Emergency contact name
Emergency contact phone
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Date of exam
Visit type
New patient
Follow-up
Location of exam
Clinic
Emergency department
Inpatient
Telehealth
Referring clinician (if applicable)
Reason for visit / chief complaint
Symptom onset date
Symptom onset pattern
Sudden
Gradual
Fluctuating
Not sure
Current symptom status
Resolved
Improving
Unchanged
Worsening
Past neurological conditions
Please Specify:
Other relevant medical history (e.g., cardiovascular disease, diabetes)
Current medications
Anticoagulant or antiplatelet use
Yes
No
Not sure
Drug and non-drug allergies
Recent head or neck injury (last 3 months)
Yes
No
Substance use that could impact the exam today
Alcohol use today
Illicit drug use today
Sedatives or opioids today
None reported
Prefer not to say
Blood pressure (mmHg)
Heart rate (bpm)
Respiratory rate (breaths/min)
Temperature (C/F)
Oxygen saturation (%)
Capillary blood glucose (if applicable)
Level of consciousness
Alert
Drowsy
Stuporous
Unresponsive
Not assessed
Orientation
Oriented x3
Oriented to person and place
Oriented to person only
Disoriented
Not assessed
Speech and language
Fluent with normal comprehension
Dysarthria
Expressive aphasia
Receptive aphasia
Mixed aphasia
Not assessed
Memory and attention
Normal
Impaired short-term memory
Impaired attention
Global impairment
Not assessed
Visual fields and acuity (CN II)
Normal
Abnormal
Not assessed
Pupils: size and reactivity (CN II/III)
Equal and reactive
Unequal or sluggish
Non-reactive
Not assessed
Extraocular movements (CN III/IV/VI)
Full, no nystagmus
Limited movement
Nystagmus present
Diplopia reported
Not assessed
Facial sensation and strength (CN V/VII)
Normal
Facial droop
Decreased facial sensation
Weakness and decreased sensation
Not assessed
Hearing (CN VIII)
Normal
Decreased right
Decreased left
Bilateral decrease
Not assessed
Palate, gag, and voice (CN IX/X)
Normal
Dysphonia or dysphagia
Absent gag
Asymmetric palate elevation
Not assessed
Shoulder shrug (CN XI)
Symmetric and strong
Weak right
Weak left
Bilateral weakness
Not assessed
Tongue movement (CN XII)
Midline and strong
Deviation right
Deviation left
Fasciculations
Not assessed
Muscle bulk
Normal
Atrophy present
Hypertrophy
Not assessed
Muscle tone
Normal
Spasticity
Rigidity
Hypotonia
Not assessed
Strength - upper limbs
Normal bilaterally
Left weakness
Right weakness
Bilateral weakness
Not assessed
Strength - lower limbs
Normal bilaterally
Left weakness
Right weakness
Bilateral weakness
Not assessed
Pronator drift
Absent
Present right
Present left
Bilateral
Not assessed
Involuntary movements observed
None observed
Tremor
Chorea
Myoclonus
Fasciculations
Other
Please Specify:
Light touch
Intact bilaterally
Decreased right
Decreased left
Stocking-glove decrease
Not assessed
Pinprick
Intact bilaterally
Decreased right
Decreased left
Stocking-glove decrease
Not assessed
Vibration and proprioception
Intact bilaterally
Decreased in feet
Decreased in hands
Hemibody decrease
Not assessed
Temperature
Intact bilaterally
Decreased right
Decreased left
Stocking-glove decrease
Not assessed
Neglect or extinction
Absent
Present
Not assessed
Finger-to-nose
Normal
Dysmetria right
Dysmetria left
Ataxia bilateral
Not assessed
Heel-to-shin
Normal
Impaired right
Impaired left
Impaired bilateral
Not assessed
Rapid alternating movements
Normal
Bradykinesia
Dysdiadochokinesia
Not assessed
Romberg
Negative
Positive
Not assessed
Gait
Normal
Antalgic
Ataxic
Spastic
Shuffling
Hemiparetic
Unable to assess
Deep tendon reflexes
Normal and symmetric
Hyperreflexia
Hyporeflexia
Asymmetric
Not assessed
Babinski (plantar) response
Downgoing right
Downgoing left
Upgoing right
Upgoing left
Equivocal
Not assessed
Clonus
Absent
Unsustained
Sustained
Not assessed
Neck stiffness
Absent
Present
Not assessed
Kernig/Brudzinski signs
Negative
Positive
Not assessed
Bladder or bowel dysfunction
No change
New urinary retention
New incontinence
Constipation
Not assessed
Orthostatic symptoms
None
Lightheaded on standing
Syncope
Not assessed
BE-FAST findings
Balance problem
Vision loss
Facial droop
Arm weakness
Speech difficulty
None
Not assessed
Last known well (date/time)
Thrombolysis contraindications present
Yes
No
Not applicable
Point-of-care glucose checked
Yes
No
Imaging ordered
None
CT head
CT angiography
MRI brain
MRA
Carotid ultrasound
EEG
Other
Please Specify:
Laboratory tests ordered
CBC
CMP
Coagulation profile
Troponin
TSH
Vitamin B12/folate
None
Other
Please Specify:
Assessment / impression
Differential considerations
Plan and recommendations
Follow-up urgency
Same day
1-3 days
1-2 weeks
1 month
As needed
Patient education provided and understanding
Confirmed understanding
Needs reinforcement
Declined education
Not applicable
Consent to neurological examination obtained
Yes
No
Patient or guardian printed name (serves as signature)
Signature date
Permission to share findings with referring clinician
Yes
No
Examiner name
Role or credentials
License or registration number
Exam date
Additional notes
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Date of birth, Medical record number or patient ID","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a neurological exam form template with key sections and a clean layout for easy use

When to use this form

You can use this neurologic exam template during clinic intake for new headaches, dizziness, unilateral weakness, numbness, tremor, or memory changes. It also fits urgent evaluations after a fall or suspected stroke, post-op neuro checks, and telehealth follow-ups to track progress. Standardized fields help you document cranial nerves, motor strength, sensation, coordination, gait, and mental status, so you can compare visits and spot red flags sooner. For context on comorbid risks and lifestyle factors, add the Health risk assessment questionnaire form. If blood pressure may influence symptoms, pair it with the Blood pressure monitoring form to trend vitals over time. Clear, structured notes support referrals, billing, and patient instructions.

Must Ask Neurological Exam Questions

  1. When did the symptoms start and how have they changed?

    Onset and trajectory help you distinguish acute, subacute, and chronic patterns, guiding differential diagnosis and urgency. A clear timeline also supports decisions about imaging, labs, and follow-up intervals.

  2. Which functions are affected (strength, sensation, speech, vision, balance), and is it one-sided?

    Localizing deficits narrows the lesion site and reduces unnecessary testing. Noting lateralization flags stroke syndromes and helps prioritize time-sensitive care.

  3. Have there been triggers or context such as head injury, infection, new medications, or substance use?

    Identifying precipitants prevents missed reversible causes like drug effects or metabolic issues. You can tailor counseling and safety planning based on the context.

  4. How do these problems affect work, driving, and daily tasks?

    Functional impact guides restrictions and accommodations. When needed, you can document them through the Physician statement form.

  5. Are you receiving or willing to start physical, occupational, or speech therapy?

    Readiness for therapy shapes the care plan and referral urgency. If referral is indicated, capture details for the Rehab application form.

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