FORM 22: FIELD NEUROLOGICAL EXAM RECORD FORM
Diver’s Name: ...................................................................
Examiner’s Name: .......................................
Date: ......................
Initial Complaint: ................................................................................................................................................................................
............................................................................................................................................................................................................
TIME
:
:
:
:
:
:
:
:
:
:
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Mental Status: Does he/she
know
1. His/her name?
2. Where he/she is?
3. Time of day?
4. Most recent activity?
5.. Speech is clear/correct
Sight:
1. Correctly counts fingers?
2. Vision clear?
Eye movements:
1. Move in all four
directions?
2. Nystagmus absent?
Facial Movements:
1. Teeth clench OK?
2. Able to wrinkle forehead
3. Tongue moves in all
directions
4. Smile is symmetrical?
Head & Shoulder
Movements:
1. Adam’s apple movement?
2. Shoulder shrug normal,
equal?
3. Head movement normal,
equal?
Hearing:
1. Normal for that diver?
2. Equal in both ears?
Sensations: Present, normal
and 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 and symmetrical for:
1. Arms
1
2. Legs
3. Hand grips
4. Feet
Balance and Coordination:
1. Romberg OK?
2. Pulse
3. Respiration
Nystagmus – involuntary oscillation of the eyeball. Usually lateral, but sometimes rotary or vertical.
Romberg – Patient stands bare footed with feet heel to toe, arms crossed over chest, eyes closed and attempts to remain
upright.
2