Neurosensory Assessment Tool

Subjective (Reports)

History of brain injury, trauma, stroke (residual effects):______________________________________________
Fainting spells/dizziness:_____________________ Headaches (location/type/frequency):__________________
Tingling/numbness/weakness (location):__________________________________________________________
Seizures:______ History/onset:______ Type (e.g., generalized, partial):______ Frequency:______ 
Aura (describe):______
Postictal state:__________________________________How controlled:________________________________
Vision loss/changes:____ Glasses/contacts:____ Last exam:____ Glaucoma:____ Cataract:____ Eye surgery (type/date):____
Hearing loss:__________________ Sudden/gradual:__________________ Hearing aids:__________________ Last exam:__________________
Sense of smell (changes):____________________________________ Epistaxis:____________________________________
Sense of taste (changes):_______________________________________________________________________
Other:_______________________________________________________________________________________

Objective (Exhibits)

Mental status (note duration of change):
Oriented: Time:__________________ Place:__________________ Person:__________________ Situation:__________________
Check all that apply:_________ Alert:_________ Drowsy:_________ Lethargic:_________ Stuporous:_________ Comatose:_________
Cooperative:____________ Follows commands:____________ Agitated/restless:____________ Combative:____________
Delusions (describe):____________________________ Hallucinations (describe):_________________________
Affect (describe):____________________________________ Speech:______________________________________________
Memory:Recent:_________________________________ Remote:_________________________________
Pupil shape:_______________________ Size/reaction: R/L:_______________________ Accommodation:_______________________
Facial droop:______________________________________________ Swallowing:_____________________________________________
Handgrasp/release, R:______________________________________ L:______________________________________________________
Coordination:_______________________ Balance:_______________________ Walking:_______________________
Deep tendon reflexes (present/absent/location):_________ Tremors:________ Posturing:________ Paralysis (L/R):_______