Patient Identification. ___ ___-___ ___ ___-___ ___ ___
Pt. Date of Birth ___ ___/___ ___/___ ___
Hospital ________________________(___ ___-___ ___)
Date of Exam ___ ___/___ ___/___ ___
Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days
[ ] 3 months [ ] Other ________________________________(___ ___)
Time: ___ ___:___ ___ [ ]am [ ]pm
Person Administering Scale _____________________________________
Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go
back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does,
not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work
quickly. Except where indicated, the patient should not be coached (i.e., repeated requests to patient to make a special effort).
Instructions Scale Definition Score
1a. Level of Consciousness: The investigator must choose a 0= Alert; keenly responsive.
response if a full evaluation is prevented by such obstacles as an 1= Not alert; but arousable by minor stimulation to obey,
endotracheal tube, language barrier, orotracheal trauma/bandages. answer, or respond.
A 3 is scored only if the patient makes no movement (other than 2= Not alert; requires repeated stimulation to attend, or is
reflexive posturing) in response to noxious stimulation. obtunded and requires strong or painful stimulation to
make movements (not stereotyped). ______
3= Responds only with reflex motor or autonomic effects or
totally unresponsive, flaccid, and areflexic.
1b. LOC Questions: The patient is asked the month and his/her age. 0= Answers both questions correctly.
The answer must be correct - there is no partial credit for being close.
Aphasic and stuporous patients who do not comprehend the 1= Answers one question correctly.
______
questions will score 2. Patients unable to speak because of
endotracheal intubation, orotracheal trauma, severe dysarthria from Answers neither question correctly.
2=
any cause, language barrier, or any other problem not secondary to
aphasia are given a 1. It is important that only the initial answer be
graded and that the examiner not "help" the patient with verbal or
non-verbal cues.
1c. LOC Commands: The patient is asked to open and close the 0 = Performs both tasks correctly.
eyes and then to grip and release the non-paretic hand. Substitute
another one step command if the hands cannot be used. Credit is 1 = Performs one task correctly.
given if an unequivocal attempt is made but not completed due to
weakness. If the patient does not respond to command, the task
should be demonstrated to him or her (pantomime), and the result 2 = Performs neither task correctly.
______
scored (i.e., follows none, one or two commands). Patients with
trauma, amputation, or other physical impediments should be given
suitable one-step commands. Only the first attempt is scored.
2. Best Gaze: Only horizontal eye movements will be tested. 0 = Normal.
Voluntary or reflexive (oculocephalic) eye movements will be scored,
but caloric testing is not done. If the patient has a conjugate 1 = Partial gaze palsy; gaze is abnormal in one or both eyes, but
deviation of the eyes that can be overcome by voluntary or reflexive forced deviation or total gaze paresis is not present.
activity, the score will be 1. If a patient has an isolated peripheral ______
nerve paresis (CN III, IV or VI), score a 1. Gaze is testable in all 2 = Forced deviation, or total gaze paresis not overcome by the
aphasic patients. Patients with ocular trauma, bandages, pre- oculocephalic maneuver.
existing blindness, or other disorder of visual acuity or fields should
Rev 10/1/2003
, Patient Identification. ___ ___-___ ___ ___-___ ___ ___
Pt. Date of Birth ___ ___/___ ___/___ ___
Hospital ________________________(___ ___-___ ___)
Date of Exam ___ ___/___ ___/___ ___
be tested with reflexive movements, and a choice made by the
investigator. Establishing eye contact and then moving about the
patient from side to side will occasionally clarify the presence of a
partial gaze palsy.
Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days
[ ] 3 months [ ] Other ________________________________(___ ___)
3. Visual: Visual fields (upper and lower quadrants) are tested by 0 = No visual loss.
confrontation, using finger counting or visual threat, as appropriate.
Patients may be encouraged, but if they look at the side of the 1 = Partial hemianopia.
moving fingers appropriately, this can be scored as normal. If there is
unilateral blindness or enucleation, visual fields in the remaining eye ______
2 = Complete hemianopia.
are scored. Score 1 only if a clear-cut asymmetry, including
quadrantanopia, is found. If patient is blind from any cause, score 3.
Double simultaneous stimulation is performed at this point. If there is 3 = Bilateral hemianopia (blind including cortical blindness).
extinction, patient receives a 1, and the results are used to respond to
item 11.
4. Facial Palsy: Ask – or use pantomime to encourage – the patient 0 = Normal symmetrical movements.
to show teeth or raise eyebrows and close eyes. Score symmetry of 1 = Minor paralysis (flattened nasolabial fold, asymmetry on
grimace in response to noxious stimuli in the poorly responsive or smiling).
non-comprehending patient. If facial trauma/bandages, orotracheal 2 = Partial paralysis (total or near-total paralysis of lower face).
tube, tape or other physical barriers obscure the face, these should 3 = Complete paralysis of one or both sides (absence of facial ______
be removed to the extent possible. movement in the upper and lower face).
5. Motor Arm: The limb is placed in the appropriate position: extend 0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds.
the arms (palms down) 90 degrees (if sitting) or 45 degrees (if 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10
supine). Drift is scored if the arm falls before 10 seconds. The seconds; does not hit bed or other support.
aphasic patient is encouraged using urgency in the voice and 2 = Some effort against gravity; limb cannot get to or maintain (if
pantomime, but not noxious stimulation. Each limb is tested in turn, cued) 90 (or 45) degrees, drifts down to bed, but has some effort
beginning with the non-paretic arm. Only in the case of amputation or against gravity.
joint fusion at the shoulder, the examiner should record the score as 3 = No effort against gravity; limb falls.
untestable (UN), and clearly write the explanation for this choice. 4 = No movement.
UN = Amputation or joint fusion, explain: _____________________
5a. Left Arm
5b. Right Arm ______
______
Rev 10/1/2003
Pt. Date of Birth ___ ___/___ ___/___ ___
Hospital ________________________(___ ___-___ ___)
Date of Exam ___ ___/___ ___/___ ___
Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days
[ ] 3 months [ ] Other ________________________________(___ ___)
Time: ___ ___:___ ___ [ ]am [ ]pm
Person Administering Scale _____________________________________
Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go
back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does,
not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work
quickly. Except where indicated, the patient should not be coached (i.e., repeated requests to patient to make a special effort).
Instructions Scale Definition Score
1a. Level of Consciousness: The investigator must choose a 0= Alert; keenly responsive.
response if a full evaluation is prevented by such obstacles as an 1= Not alert; but arousable by minor stimulation to obey,
endotracheal tube, language barrier, orotracheal trauma/bandages. answer, or respond.
A 3 is scored only if the patient makes no movement (other than 2= Not alert; requires repeated stimulation to attend, or is
reflexive posturing) in response to noxious stimulation. obtunded and requires strong or painful stimulation to
make movements (not stereotyped). ______
3= Responds only with reflex motor or autonomic effects or
totally unresponsive, flaccid, and areflexic.
1b. LOC Questions: The patient is asked the month and his/her age. 0= Answers both questions correctly.
The answer must be correct - there is no partial credit for being close.
Aphasic and stuporous patients who do not comprehend the 1= Answers one question correctly.
______
questions will score 2. Patients unable to speak because of
endotracheal intubation, orotracheal trauma, severe dysarthria from Answers neither question correctly.
2=
any cause, language barrier, or any other problem not secondary to
aphasia are given a 1. It is important that only the initial answer be
graded and that the examiner not "help" the patient with verbal or
non-verbal cues.
1c. LOC Commands: The patient is asked to open and close the 0 = Performs both tasks correctly.
eyes and then to grip and release the non-paretic hand. Substitute
another one step command if the hands cannot be used. Credit is 1 = Performs one task correctly.
given if an unequivocal attempt is made but not completed due to
weakness. If the patient does not respond to command, the task
should be demonstrated to him or her (pantomime), and the result 2 = Performs neither task correctly.
______
scored (i.e., follows none, one or two commands). Patients with
trauma, amputation, or other physical impediments should be given
suitable one-step commands. Only the first attempt is scored.
2. Best Gaze: Only horizontal eye movements will be tested. 0 = Normal.
Voluntary or reflexive (oculocephalic) eye movements will be scored,
but caloric testing is not done. If the patient has a conjugate 1 = Partial gaze palsy; gaze is abnormal in one or both eyes, but
deviation of the eyes that can be overcome by voluntary or reflexive forced deviation or total gaze paresis is not present.
activity, the score will be 1. If a patient has an isolated peripheral ______
nerve paresis (CN III, IV or VI), score a 1. Gaze is testable in all 2 = Forced deviation, or total gaze paresis not overcome by the
aphasic patients. Patients with ocular trauma, bandages, pre- oculocephalic maneuver.
existing blindness, or other disorder of visual acuity or fields should
Rev 10/1/2003
, Patient Identification. ___ ___-___ ___ ___-___ ___ ___
Pt. Date of Birth ___ ___/___ ___/___ ___
Hospital ________________________(___ ___-___ ___)
Date of Exam ___ ___/___ ___/___ ___
be tested with reflexive movements, and a choice made by the
investigator. Establishing eye contact and then moving about the
patient from side to side will occasionally clarify the presence of a
partial gaze palsy.
Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days
[ ] 3 months [ ] Other ________________________________(___ ___)
3. Visual: Visual fields (upper and lower quadrants) are tested by 0 = No visual loss.
confrontation, using finger counting or visual threat, as appropriate.
Patients may be encouraged, but if they look at the side of the 1 = Partial hemianopia.
moving fingers appropriately, this can be scored as normal. If there is
unilateral blindness or enucleation, visual fields in the remaining eye ______
2 = Complete hemianopia.
are scored. Score 1 only if a clear-cut asymmetry, including
quadrantanopia, is found. If patient is blind from any cause, score 3.
Double simultaneous stimulation is performed at this point. If there is 3 = Bilateral hemianopia (blind including cortical blindness).
extinction, patient receives a 1, and the results are used to respond to
item 11.
4. Facial Palsy: Ask – or use pantomime to encourage – the patient 0 = Normal symmetrical movements.
to show teeth or raise eyebrows and close eyes. Score symmetry of 1 = Minor paralysis (flattened nasolabial fold, asymmetry on
grimace in response to noxious stimuli in the poorly responsive or smiling).
non-comprehending patient. If facial trauma/bandages, orotracheal 2 = Partial paralysis (total or near-total paralysis of lower face).
tube, tape or other physical barriers obscure the face, these should 3 = Complete paralysis of one or both sides (absence of facial ______
be removed to the extent possible. movement in the upper and lower face).
5. Motor Arm: The limb is placed in the appropriate position: extend 0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds.
the arms (palms down) 90 degrees (if sitting) or 45 degrees (if 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10
supine). Drift is scored if the arm falls before 10 seconds. The seconds; does not hit bed or other support.
aphasic patient is encouraged using urgency in the voice and 2 = Some effort against gravity; limb cannot get to or maintain (if
pantomime, but not noxious stimulation. Each limb is tested in turn, cued) 90 (or 45) degrees, drifts down to bed, but has some effort
beginning with the non-paretic arm. Only in the case of amputation or against gravity.
joint fusion at the shoulder, the examiner should record the score as 3 = No effort against gravity; limb falls.
untestable (UN), and clearly write the explanation for this choice. 4 = No movement.
UN = Amputation or joint fusion, explain: _____________________
5a. Left Arm
5b. Right Arm ______
______
Rev 10/1/2003
