Name: _________________________ Date: ____________________

INSTRUCTIONS: Please assist the doctor by completing the following information.

BEHAVIOR:
What are behaviors like? Specify if there are difficulties with such items as screaming inappropriately, talking excessively, temper tantrums, etc.

SPEECH AND LANGUAGE, COGNITION:


1. Please describe the patient's speech and language. (What sounds, phrases or sentences can the patient vocalize?)

2. Can the patient name items, repeat things being said, understand what is being said?

3. Can the patient write or read?

4. Does the nature of the speech make sense?

5. Can the patient attend to his or her appearance?

6. Does the patient tend to laugh or cry without control? Does the crying or laughter occur suddenly without reason?

7. Is the patient oriented to person, place and time? What is the patient's memory like?

8. Can the patient perform any calculations?

9. How complex a command could the patient follow?

10. Does the patient seem to have hallucinations or delusions?

11. Is the patient depressed?

12. Does the patient tend to repeat sounds or phrases inappropriately when speaking?

    CRANIAL NERVES:
    

13. How is the patient's vision?

14. Does the patient have double vision?

15. Are there abnormal eye movements?

16. Is there any drooping of one side of the face?

17. How is the patient's hearing?

18. Is there any swallowing problem?

19. Can the patient shrug his or her shoulders? Can the patient turn his or her head from side to side?

20. Can the patient stick out his or her tongue?

    MOTOR:
    

21. What is the strength like in the right arm?

22. What is the strength like in the left arm?

23. What is the strength like in the right leg?

24. What is the strength like in the left leg?

25. Does the patient have rigid tone in one or more limbs of the body?

26. Are there any sudden abnormal movements such as twisting movements, stretching movements, jerking movements, tremors or shaking movements, etc.?

    SENSORY:
    

27. Does the patient have difficulty feeling things in any part of the body? Please specify where.

    COORDINATION AND GAIT:
    

28. Can the patient walk? What is the walking like?

29. Can the patient sit upright on a flat surface like his or her bed?