Diver Neuro Checklist Template
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1
2Rapid Field Neuro Checksheet
Diver’s Name: _______________________________ Name of Examiner: _______________________
Date: _______ Initial Complaint: ________________________________________________________
Time
Notes
Mental Status: Do they know:
Yes
No
Yes
No
Yes
No
Yes
No
1) Their name?
2) Where they are?
3) Time of day?
4) Most recent activity?
5) Speech is clear, correct?
Sight:
Yes
No
Yes
No
Yes
No
Yes
No
1) Correctly counts fingers?
2) Vision clear?
Eye Movements:
Yes
No
Yes
No
Yes
No
Yes
No
1) Move all four directions?
2) Nystagmus absent?
Facial Movements?
Yes
No
Yes
No
Yes
No
Yes
No
1) Teeth clench OK?
2) Able to wrinkle forehead?
3) Tongue moves all directions?
4) Smile symmetrical?
Head/Shoulder Movements:
Yes
No
Yes
No
Yes
No
Yes
No
1) “Adams Apple” moves?
2) Shoulder shrug normal, equal?
3) Head movements normal, equal?
Hearing:
Yes
No
Yes
No
Yes
No
Yes
No
1) Normal for that diver?
2) Equal both ears?
Sensations: Present, normal and
Yes
No
Yes
No
Yes
No
Yes
No
Symmetrical across?
1) Face
2) Chest
3) Abdomen
4) Arms (front)
5) Hands
6) Legs (front)
7) Feet
8) Back
9) Arms (back)
10) Buttocks
11) Legs (back)
Muscle Tone: Present, normal
Yes
No
Yes
No
Yes
No
Yes
No
and symmetrical for:
1) Arms
2) Hand grips
3) Legs
4) Feet
Balance and Coordination:
Yes
No
Yes
No
Yes
No
Yes
No
1) Romberg OK?
2) If Supine: Heel-shin slide OK?
3) Alternating hand movements OK?
Vital Signs:
1) Blood pressure
2) Pulse
3) Respirations
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