Hospital Stroke Evaluation Form
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1
2USAMC / DEPARTMENT OF NEUROLOGY
NAME: ______________________________________________
Stroke Center - History and Physical/Consultation
DOB: _____________________USA#:____________________
Date of evaluation _______________________
REF PHYSICIAN: _____________________________________
Last seen normal date: ___________ time: __________
Arrival date: ____________ time: ____________
_________
Stroke code called:
Baseline function:
Indep
Assist
Total care
Method of transport : EMS / Family
CHIEF COMPLAINT:
HPI:
Location, quality, severity, duration, timing, context, modifying factors, assoc. S/Sx, or describe status of 3 chronic conditions.
ROS: list abnormalities
Past medical history
Medications
None
DM
CVA/TIA
See “Medication List Form”; I have
norm
abn
Afib/flut
Dyslipid
PVD
reviewed and confirmed the information.
Constitut
___________________________
Eyes
___________________________
CAD/MI
CHF
SickleCel
Otherwise list:
CrtdSten
HTN
Cancer
ENT
___________________________
CRF
COPD
Infection
Card/Vasc
___________________________
Resp
___________________________
SleepAp
Major Surgery (list)
Other:
GI
___________________________
GU
___________________________
Family history
Muscle
___________________________
None
HTN
CVA
Skin
___________________________
CAD/MI
Cancer
Neuro
___________________________
Other:
Psych
___________________________
Social history
Endo
___________________________
Hem/Lymph
___________________________
Tobacco ___________ PPD x________ yrs
Alcohol _____________________ per day
Allergy/Imm
___________________________
Recr Drugs_________________________
Unable to obtain PFSH due to
Unable to obtain ROS due to
____________________________________
Other:_____________________________
VITAL SIGNS: BP___________ P______ R______ T______ HGT______ WGT_____ lb _____kg
NIH STROKE SCALE
1a
LOC
0-alert
1-drowsy
2-stuporous
3-coma
1b
LOC-questions
0-both correct
1-one correct
2-both incorrect
1-obeys one
1c
LOC-commands
0-obeys both correctly
2-both incorrect
correctly
2
Gaze
0-normal eye movement
1-partial gaze palsy
2-forced deviation
3
Visual fields
0-no visual loss
1-partial hemianopia
2-complete hemianopia
3-bilateral hemianopia
4
Facial movement
0-normal
1-minor paresis
2-partial paresis
3-complete palsy
2-some effort against
3-no effort against
Motor function LEFT arm
0-no drift
1-drift
4-no movement
untestable
gravity
gravity
5
2-some effort against
3-no effort against
Motor function RIGHT arm
0-no drift
1-drift
4-no movement
untestable
gravity
gravity
2-some effort against
3-no effort against
Motor function LEFT leg
0-no drift
1-drift
4-no movement
untestable
gravity
gravity
6
2-some effort against
3-no effort against
Motor function RIGHT leg
0-no drift
1-drift
4-no movement
untestable
gravity
gravity
2-present unilaterally in
1-present unilaterally
7
Limb ataxia
0 absent
both arm and leg or
in arm or leg
bilaterally
8
Sensation
0 normal
1-partial loss
2-dense loss
1-mild to moderate
9
Best language
0 no aphasia
2-severe aphasia
3-mute
aphasia
1-mild to moderate
2-near unintelligible or
10
Dysarthria
0-normal articulation
dysarthria
worse
11
Neglect (extinct/inattention)
0-no neglect
1-partial neglect
2-complete neglect
NIH STROKE SCALE TOTAL SCORE: ____________________
<**SEE PAGE 2**>
file under tab #5 – history and physical
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