Asociación Ayuda Enfermo Neuroquirúrgico (AAEN)

Demographic Information

Name:

Age:

Gender:

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Male
Female
Other
Prefer not to say

Place:

Occupation:

Educational Status:

Income Group:

Handedness:

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Right
Left
Ambidextrous

Spoken Language:

Food Preference:

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Veg
Non-Veg
Mixed

Sleep Pattern:

Pain History (Cervical/Thoracic/Lower Back)

Onset:

Duration:

Progression:

Location:

Nature Type:

Radiation:

Aggravating Factors:

Relieving Factors:

Continuous Mechanical:

Associated With Specific Movements:

Neck Tilt:

Associated With Neurological Deficits:

Neurological Claudication:

Erectile Dysfunction Priapism:

Previous Spinal Surgery or Procedures:

Other Malignancies:

Night Cries:

Local Spinal Swelling:

Scoliosis or Kyphosis:

Weakness History

Limbs Involved:

Onset:

Duration:

Progression:

Hand Grip Functional Deficit:

Foot Drop Buckling Knees:

Wasting Flattening Thinning:

Fasciculation:

Tremors:

Stiffness of Limbs:

Difficulty Walking:

Recovery Pattern:

Giddiness History

Onset:

Duration:

Progression:

Particular Position of Occurrence:

Associated History:

Ear Discharge:

Tinnitus:

Hearing Loss:

Vomiting:

Headache History

Onset:

Duration:

Progression:

Ictus:

Location:

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Hemi-cranial
Holo-cranial
Local

Nature/Type:

Radiation:

Aggravating Factors:

Relieving Factors:

Diurnal Variation:

Associated Symptoms:

Vomiting:

Loss of Consciousness:

Visual Blurring:

Diplopia:

Seizure History

Age of Onset:

Type of Seizure:

Progression of Seizure:

Typical Time of Occurrence:

Prodrome:

Aura:

Ictus:

Time of Onset:

Activity at Onset:

Precipitating Factors:

Event Definition:

Progression of Symptoms:

Duration:

Time to Recovery:

Postictal Confusion:

Postictal Amnesia:

Postictal Deficits:

Frequency of Seizures:

Last Seizure Episode:

Imbalance and Incoordination

Swaying While Walking:

Slurring Speech:

Tremors on Doing Action:

Shaking Head Body at Rest:

Overshooting While Reaching:

Clumsiness Inability Alternating Movements:

Change in Dark Narrow Corridor:

Medication History

Name of Drug:

Duration:

Compliance:

Side/Adverse Effects:

Neurological Examination

Consciousness:

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Alert
Drowsy
Stuporous
Comatose

Attention Span:

Concentration:

Orientation Time:

Orientation Place:

Orientation Person:

Language Spontaneous Speech:

Language Word Output:

Language Prosody:

Grammar Word Finding Difficulty:

Grammar Paraphrasias Word Substitutions:

Grammar Neologisms:

Grammar Jargon Speech:

Fluency Animal Naming Test:

Fluency FAS Test:

Comprehension:

Repetition:

Naming:

Reading:

Writing:

Abstract Sense:

Memory Immediate:

Memory Recent:

Memory Remote:

New Learning Ability:

Visual Memory:

Skull, Spine, and Meninges

Skull Examination:

Spine Examination:

Meninges Examination:

Title

Muscle Power Examination

Upper Limb

Right Shoulder Flexion:

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0
1
2
3
4
5

Right Shoulder Extension:

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---------
0
1
2
3
4
5

Right Shoulder Abduction:

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---------
0
1
2
3
4
5

Right Shoulder Adduction:

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---------
0
1
2
3
4
5

Right Elbow Flexion:

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---------
0
1
2
3
4
5

Right Elbow Extension:

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---------
0
1
2
3
4
5

Right Wrist Flexion:

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---------
0
1
2
3
4
5

Right Wrist Extension:

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---------
0
1
2
3
4
5

Right Finger Flexion:

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---------
0
1
2
3
4
5

Right Finger Extension:

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---------
0
1
2
3
4
5

Right Finger Abduction:

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0
1
2
3
4
5

Right Finger Adduction:

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---------
0
1
2
3
4
5

Left Shoulder Flexion:

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---------
0
1
2
3
4
5

Left Shoulder Extension:

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---------
0
1
2
3
4
5

Left Shoulder Abduction:

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---------
0
1
2
3
4
5

Left Shoulder Adduction:

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---------
0
1
2
3
4
5

Left Elbow Flexion:

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---------
0
1
2
3
4
5

Left Elbow Extension:

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---------
0
1
2
3
4
5

Left Wrist Flexion:

Left Wrist Extension:

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---------
0
1
2
3
4
5

Left Finger Flexion:

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---------
0
1
2
3
4
5

Left Finger Extension:

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---------
0
1
2
3
4
5

Left Finger Abduction:

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0
1
2
3
4
5

Left Finger Adduction:

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0
1
2
3
4
5

Lower Limb

Right Hip Flexion:

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---------
0
1
2
3
4
5

Right Hip Extension:

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---------
0
1
2
3
4
5

Right Hip Abduction:

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---------
0
1
2
3
4
5

Right Hip Adduction:

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---------
0
1
2
3
4
5

Right Knee Flexion:

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---------
0
1
2
3
4
5

Right Knee Extension:

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---------
0
1
2
3
4
5

Right Ankle Dorsiflexion:

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---------
0
1
2
3
4
5

Right Ankle Plantarflexion:

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0
1
2
3
4
5

Right Ankle Inversion:

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0
1
2
3
4
5

Right Ankle Eversion:

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0
1
2
3
4
5

Right Toes Flexion:

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---------
0
1
2
3
4
5

Right Toes Extension:

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---------
0
1
2
3
4
5

Left Hip Flexion:

---------

---------
0
1
2
3
4
5

Left Hip Extension:

---------

---------
0
1
2
3
4
5

Left Hip Abduction:

---------

---------
0
1
2
3
4
5

Left Hip Adduction:

---------

---------
0
1
2
3
4
5

Left Knee Flexion:

---------

---------
0
1
2
3
4
5

Left Knee Extension:

---------

---------
0
1
2
3
4
5

Left Ankle Dorsiflexion:

---------

---------
0
1
2
3
4
5

Left Ankle Plantarflexion:

---------

---------
0
1
2
3
4
5

Left Ankle Inversion:

---------

---------
0
1
2
3
4
5

Left Ankle Eversion:

---------

---------
0
1
2
3
4
5

Left Toes Flexion:

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---------
0
1
2
3
4
5

Left Toes Extension:

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---------
0
1
2
3
4
5

Reflex Examination

Abdominal:

Plantar:

Hoffman's:

Finger Flexion:

Cremasteric:

Bulbocavernous:

Anal Reflex:

Biceps:

Triceps:

Supinator:

Knee:

Ankle:

Cerebellar Examination

Nystagmus:

Titubation:

Speech:

Truncal Ataxia:

Dysdiadochokinesia:

Finger Nose Test:

Finger Nose Finger Test:

Rebound Phenomenon:

Intention Tremors:

Knee Heel Test:

Stance and Gait:

Sensory Examination

Fine Touch:

Crude Touch:

Pain:

Temperature:

Vibration Sense:

Joint Position Sense:

Rhomberg's Test:

Drives

Appetite Food Faddism:

Weight Loss Gain:

Hyper Hypo Sexuality:

Sleep:

Motor Phenomenon

Tremor:

Myoclonus:

Seizure:

Ataxia:

Gait Change:

Bradykinesia:

Systemic Examination

Cardiovascular:

Respiratory System:

Per Abdomen:

Spine Examination:

Spine Tenderness:

Deformity:

Neck Movements:

Straight Leg Rising Test:

Autonomic System

Cardiovascular Reflexes:

Sweating Abnormalities:

Demographic Information

Pain History (Cervical/Thoracic/Lower Back)

Weakness History

Giddiness History

Headache History

Seizure History

Bowel and Bladder Symptoms

Sensory Disturbances

Imbalance and Incoordination

Medication History

Neurological Examination

Skull, Spine, and Meninges

Cranial Nerve Examination

I. Olfactory

II. Optic

III, IV, VI. Oculomotor, Trochlear, Abducens

V. Trigeminal

VII. Facial

VIII. Vestibulocochlear

IX, X. Glossopharyngeal, Vagus

XI. Spinal Accessory

XII. Hypoglossal

Muscle Power Examination

Upper Limb

Lower Limb

Reflex Examination

Cerebellar Examination

Sensory Examination

Psychiatric Symptoms

Mental Functions History

Mood/Mental Phenomenon

Drives

Motor Phenomenon

General Examination

Systemic Examination

Autonomic System

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