Pre-Fight Neurological Evaluation Form

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PRE­FIGHT NEUROLOGICAL EVALUATION FORM
NAME: ___________________________________________________ DATE: 
_____________________
AGE: __________________________ HANDED:
RIGHT _______________  LEFT 
________________
YEARS BOXING: _______________   FIGHT RECORD:  _______________
  LAST 
FIGHT: _____________
OCCUPATION: 
________________________________________________________________________
COMMENTS: 
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
NEUROLOGICAL EXAMINATION:
VITAL SIGNS:   BP: _______/_______   PULSE: _______   HEIGHT: _______ WEIGHT: 
_______
MENTAL STAUTS EXAM: 
 NORMAL
 ABNORMAL
CRANIAL NERVES:
 NORMAL
 ABNORMAL
MOTOR EXAM:
 NORMAL
 ABNORMAL
DTR EXAM:
 NORMAL
 ABNORMAL
CEREBELLAR:
 NORMAL
 ABNORMAL
SENSORY EXAM:
 NORMAL
 ABNORMAL
GAIT EXAM:
 NORMAL
 ABNORMAL
COMMENTS:
_________________________________________________________________________

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