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Pain scale
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Complete Normal Neuro Exam
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Brief Normal Neuro Exam
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Abnormalities on neuro exam
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Abnormality on neuro exam
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Abnormality on neuro exam
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Abnormality on neuro exam
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Abnormality on neuro exam
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Abnormality on neuro exam
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Abnormality on neuro exam
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Abnormality on neuro exam
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Abnormality on neuro exam
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Abnormality on neuro exam
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Mini-Mental Status Exam
• • •
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MMSE score
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MoCA Test
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MoCA Score
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CLOSE YOUR EYES
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Mental Status Comments
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Mood appropriate?
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Mood comments
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Affect appropriate?
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Affect comments
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Thought process normal?
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Thought process comments
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Full Mental Exam done?
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General Appearance
• • •
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Psychomotor Behavior
• • •
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Mood and Affect
• • •
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Speech
• • •
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Cognition
• • •
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Thought Patterns
• • •
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Level of Consciousness
• • •
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Remainder of exam normal
|
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Mental status (detailed)
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Mental status
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Speech / Language (detailed)
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Speech / Language
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Cranial Nerves 1-12 (detailed)
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Cranial nerves 1-12
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Cranial Nerve 1 (detailed)
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Cranial nerve 1
|
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Cranial Nerve 2 (detailed)
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Cranial nerve 2
|
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Cranial Nerves 3,4,6 (detailed)
|
Cranial nerves 3,4,6
|
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Cranial Nerve 5 (detailed)
|
Cranial nerve 5
|
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Cranial Nerve 7 (detailed)
|
Cranial nerve 7
|
|
Cranial Nerve 8 (detailed)
|
Cranial nerve 8
|
|
Cranial Nerves 9, 10 (detailed)
|
Cranial nerves 9,10
|
|
Cranial Nerve 11 (detailed)
|
Cranial nerve 11
|
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Cranial Nerve 12 (detailed)
|
Cranial nerve 12
|
|
|
|
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Neck / Cervical spine (detailed)
|
Neck / Cervical spine
|
|
Back / T, LS Spine (detailed)
|
Back / TL, LS spine
|
|
Motor / Muscle strength (detaile
|
Motor / muscle strength
|
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Reflexes (detailed)
|
Reflexes
|
|
Coordination (detailed)
|
Coordination
|
|
Sensation (detailed)
|
Sensation / sensory function
|
|
Gait and balance (detailed)
|
Gait and balance
|
|
T 25ft walk performed?
|
T-25ft result:
|
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Auscultation (detailed)
|
Auscultation
|
|
|
|
|
Exam Comments
|
|
|
LOCALIZATION 1
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LOCALIZATION 2
|
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LOCALIZATION 3
|
LOCALIZATION 4
|
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LOCALIZATION 5
|
LOCALIZATION 6
|
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|
|
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Copy Spiral Graph
|
Free Drawing
|
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|
|
|
Mental Status notes
|
|
|
Botox notes
|
|
|
NIH stroke/aphasia notes
|
|
|
|
|
|
EDSS performed?
|
EDSS Diagram 1
|
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EDSS Diagram 2
|
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EDSS Diagram 3
|
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EDSS Diagram 4
|
|
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Functional Score
|
|
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|
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0.0 / No Disability
|
2.0 / Minimal disability
|
|
3.0 / Moderate disability
|
4 / Relatively severe disability
|
|
5 / Disab. affects daily routine
|
6 / Assistance req to walk
|
|
7 / Restricted to wheelchair
|
8 / Restricted to bed or chair
|
|
9 / Confined to bed
|
Optional: EDSS Score
|
