Patient Age Gender
Reason for Visit
1. Health History
a. Any unusual frequent or unusually severe headaches?
b. Ever had any head injury?
c. Ever feel dizziness?
d. Ever had seizures?
e. Any tremors in hands or face?
f. Any weakness in any body part?
g. Any problems with coordination?
h. Any numbness or tingling?
i. Any problem swallowing?
j. Any problem speaking?
k. Past history of stroke, spinal cord injury, meningitis, congenital defect,
1. Any environmental or occupational hazards (e.g., insecticides)?
(No or Yes, Explain)
2. Physical Examination (List normal/abnormal findings)
A. Cranial Nerves I.
II.
VIII. IX, X. XI. XII.
Name:
B. Motor System Muscles Size, strength, tone Involuntary movements
Date:
Cerebellar function Rapid alternative movements Finger-Nose test Heel to shin test Gait Romberg test C. Sensory System Anterolateral tract Sharp or dull Light touch
Posterior column tract Vibration Position (kinesthesia) Tactile discrimination Stereognosis Graphesthesia D. Reflexes
(Grade 0 through +4)
Biceps Triceps Brachioradialis Patellar Achilles Plantar Right Left
Adapted from: Jarvis, C . (2020). Physical examination and health assessment (8th ed.)Study Guide. St. Louis, MO: Elsevier.
