Patient Name: | ||
Rater Name: | ||
Date: | ||
Time: | ||
Mentation | Score | |
Level consciousness | Alert | 3.0 |
Drowsy | 1.5 | |
Orientation | Oriented | 1.0 |
Disoriented/NA | 0.0 | |
Speech | Normal | 1.0 |
Expressive deficit | 0.5 | |
Receptive deficit | 0.0 | |
TOTAL: | ||
Motor functions (no comprehension deficit) | Weakness | Score |
Face | None | 0.5 |
Present | 0.0 | |
Arm: proximal | None | 1.5 |
Mild | 1.0 | |
Significant | 0.5 | |
Total | 0 | |
Arm: distal | None | 1.5 |
Mild | 1.0 | |
Significant | 0.5 | |
Total | 0 | |
Leg | None | 1.5 |
Mild | 1.0 | |
Significant | 0.5 | |
Total | 0 | |
TOTAL: | ||
Motor response (comprehension deficit) | Score | |
Face | Symmetrical | .5 |
Asymmetrical | 0 | |
Arms | Equal | 1.5 |
Unequal | 0 | |
Legs | Equal | 1.5 |
Unequal | 0 | |
TOTAL: |
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