Item number | Item name | Scoring guide | Patient score |
1b | LOC questions | 0 = Answers both correctly | _____ |
1 = Answers one correctly |
2 = Answers neither correctly |
1c | LOC commands | 0 = Performs both tasks correctly | _____ |
1 = Performs one task correctly |
2 = Performs neither task |
2 | Gaze | 0 = Normal | _____ |
1 = Partial gaze palsy |
2 = Total gaze palsy |
3 | Visual fields | 0 = No visual loss | _____ |
1 = Partial hemianopsia |
2 = Complete hemianopsia |
3 = Bilateral hemianopsia |
5a | Left arm motor | 0 = No drift | _____ |
1 = Drift before 10 seconds |
2 = Falls before 10 seconds |
3 = No effort against gravity |
4 = No movement |
5b | Right arm motor | 0 = No drift | _____ |
1 = Drift before 10 seconds |
2 = Falls before 10 seconds |
3 = No effort against gravity |
4 = No movement |
6a | Left leg motor | 0 = No drift | _____ |
1 = Drift before 5 seconds |
2 = Falls before 5 seconds |
3 = No effort against gravity |
4 = No movement |
6b | Right leg motor | 0 = No drift | _____ |
1 = Drift before 5 seconds |
2 = Falls before 5 seconds |
3 = No effort against gravity |
4 = No movement |
8 | Sensory | 0 = Normal | _____ |
1 = Abnormal |
9 | Language | 0 = Normal | _____ |
1 = Mild aphasia |
2 = Severe aphasia |
3 = Mute or global aphasia |
11 | Neglect | 0 = Normal | _____ |
1 = Mild |
2 = Severe |
Score (out of 31): | _____ |