NEUROLOGICAL
ASSESSMENT
TOOL
SUBMITTED TO SUBMITTED BY
NUEROLOGICAL ASSESSMENT
1.Baseline Data
Name Of The Client : Hospital:
Age : Ward:
Sex: Unit:
Religion: Bed No:
Nationality: Ip No:
Occupation: Doctor:
Monthly Income: D.O.A:
Address: Diagnosis:
2.Chief Compliaints
1………………………………
2………………………………
3………………………………
4………………………………
5………………………………
3. History Of Present Illness
A.Pain
Onset:Sudden……….Gradual……………
Duration:Occational…....Persistence……
Contineous…...Intermittent…….Location……….Type……
Severity……Aggrevatingfactor………
Releiving Factors……….......
B.Headache:
Onset:……….. Sudden………..Gradual…………
Duration…….Occational………Persistence…….
Continueous………..Intermittent……………
Type Of Headache:
Severity………Aggrevating Factors,……………
Relieving Factors………Associated Factors……..
Nausea……….Vomiting……….Anorexia………
Weight Loss…………..Weight Gain……………..
History Of Past Illness
Medical History:
Surgical History:
History Of Childhood Illness:
Communicable Diseases. Yes…..No…..
If Yes Specify.Chickenpox……. Mumps……..Measels……
Rubella……Jaundice……
Heriditory Diseases Yes…….No……
If Yes Specify ………Diabetic Mellitus……
Hypertension …….Cancer………..
Chronic Diseasee Yes…….No……..
Asthma Yes…….No……..
Nephrotic Syndrome Yes…… No…….
Systemic Diseases Yes…….No…….
If Yes Specify…………
Childhood Immunization
Immunized………. Non Immunized………..
History Of Allergies Yes……No……
If Yes Specify . Drug Yes……No…….
Diet Yes…..No……..
Medicine Yes…..No……..
Enivironmental Factors
Smoke………Dust……….Air………Chemical….
Previous Hospitalization Yes…..No……
If Yes Specify……….No Of Times Admitted……
Cause Of Admission………Complications…….
Out Come………Date Of Discharge………
History Of Accidents Yes……No……..
If Yes Specify Cause………
Marital Status
Married………Unmarried………
Divorce……Widow….Single……..
Type Of Family
Nuclear…..Joint………Extended……..
Broken……..No Of Family Members…..
S.No Name Relation Age/Sex Education Occupation Income Health
Family Tree
Obstetrical History
Age Of Menarche…...Menstrual cycle …….
No Bleeding Days…………
Flow Mild….Moderate……Severe….
Color Red….. Brown……White……
Consistency Fluid….Thickfluid…….Clots……. Age
At Menopause……Dusmenorrhea….
No Of Pregnancies …….
No Of Deliveries…….
No Of Children……..
Any Miscarriages(Or)Abortions
If Yes Specify…………….
Socio Economic Status
Type Of Work Moderate…….Heavy……...Sedentary………
Income….….. Individual……...Family………
Source Of Income
Employment……..Farming……Business…..
Living Area
Urban……Rural….Slums……..
Water Tap….Borewell……Ponds……
Drainage Closed……..Opened………
Housing Pucca……Kuccha…….
Ventilation Good……Poor….Windows…..
No Of Rooms……
Personal History
Brushing No Of Times…….
Frequency Of Bath……
Elimination Pattern…….
Bladder Frequency………
Constipation……Diarrhoea…….
Rest And Sleep
Bed Time…..Time Of Awekening…….
No Of Hours……..Nature Of Sleep……
Sound…..Disturbed…….
Duration Of Rest In Day Time……..
Use Of Drugs For Sleep Yes ….. No…...
Any Sleep Disturbences
Snoring…….Night Mares…..Sleep Walk……..
Exercises Yes….No……If Yes Specify….
Regular……..Irregular……….Rare……...
Habits
Coffee….Tea……Alcohol….Smoking........
Dietary Pattern
Vegatarian………..……Non Vegatarian……..
Type Of Food Intake
Wheat………Rice…..……Java…….…
Physical Examination
Head
Size…..Shape…..Dandruff…….Pediculosis……..
Headache………Dizziness……
Scalp
Hair Distribution Thick…….Scanty……Alopasia……
Texture…..Soft….Silky…….
Eyes
Symmertry……Asymmetri…….
Discharge……Use Of Spectacles…….
Conjuctivities Yes…..No…..
Pupils:Reacting To Light….Constricted……Dilated…….
Eye Lids:Infection…Sty…..Normal…..
Eye Balls:Infectious…..Normal……
Moving……Nystagmus……
Lens:Transparent….Capacity…..
Eye Brows:Hair Loss Yes….No…..
Ears:Symmetric….Asymmetric……
Pain……Discharge……..Deafness……
Hearing……Bulging……..
Lesions……….Tympanic……...
Nose:
Normal…..Septal Deviation…….
Epistaxsis…….Nasal Polyps…….
Sinusitis….Allergies………
Mouth:
Oral Mucosa…….Normal…..
Pallor…….Ulcer……Red…….Lips…..
Dry…….Moist…….Cracking……Pale…
Gums:
Pink….Red…..Swollen……Bleeding…..ulcerate……
Tongue:
Pale……red…….cynosed……smooth……..moles…….
Dry……..swelling…….alignment……….
Neck:
Normal……short……long…….
Movements:
Normal……..rigidity………thyroid………..
Chest:
Symmetric……..asymmetric………
Barrel shaped….pegion chest……..funnel chest…….
Breast:
Symmetric……..asymmetric……….
Discharges……..engourgement………..
Nipple:normal……..inverted……retracted……….
Abdomen:
Shape…….anyscars………soft…….tendreness………
Umbilicus…….shape……..position………back……..
Spinabifida……..bedsores……….
Genitalia:Male
Uretral………meatus……..
Central……..dorsal……..ventral……..scrotum…….
Descended…………un descended……….
Female:
Vulva………swelling…….discharge yes……no……..
If yes specify color…..
GLASGOW COMA SCALE
EYE opening No eye opening (1)
Opening to pain (2)
Opening to speech (3)
Spontaneous opening (4)
Verbal response No response (1)
Incomprehensible (2)
Inappropriate (3)
Confuse (4)
Oriented (5)
