1. Level of Consciousness |
1A (LOC) |
0 = Alert, keenly responsive
|
1 = Not alert, arouses to minor stimulation |
2 = Not alert, requires repeated stimulation to arouse |
3 = Response with only reflexes or totally unresponsive |
- |
1B (LOC Questions - request current month and age) |
0 = Answers both questions right |
1 = Answers one question correct, or dysarthric/intubated |
2 = Answers neither question correctly, or aphasic |
- |
- |
1C (LOC Commands - blink eyes & squeeze hands) |
0 = Performs both tasks correctly |
1 = Performs one task correctly |
2 = Performs neither task correctly |
- |
- |
2. Best Gaze (Test horizontal eye movements) |
0 = Normal |
1 = Partial gaze palsy |
2 = Forced deviation |
- |
- |
3. Visual (Visual fields tested by confrontation) |
0 = No visual loss |
1 = Partial hemianopia |
2 = Complete hemianopia |
3 = Bilateral hemianopia (including cortical blindness) |
- |
4. Facial Palsy (Show teeth, raise eyebrows, close eyes) |
0 = Normal |
1 = Minor paralysis (flattened nasolabial folds, asymmetry on smile) |
2 = Some effort against gravity, cannot maintain 90o (or 45o), drifts down to bed |
|
|
5. Motor Arm (Extend the arms (palms down) 90o (if sitting) or 45o (if supine))
5A = Left Arm; 5B = Right Arm
UN = Amputation or joint fusion, explain why untestable |
0 = No drift, held for full 10 seconds |
1 = Drift down before 10 seconds, but not hitting bed or support |
2 = Some effort against gravity, cannot maintain 90o (or 45o), drifts down to bed |
3 = No effort against gravity, limb falls |
4 = No movement |
6. Motor Leg (Hold leg at 30 o while supine)
6A = Left Leg; 6B = Left Leg
UN = Amputation or joint fusion, explain why untestable |
0 = No drift, held for full 5 seconds |
1 = Drift down before 5 seconds, but not hitting bed |
2 = Some effort against gravity, but leg falls to bed by 5 seconds |
3 = No effort against gravity, leg falls |
4 = No movement |
7. Limb Ataxia (Bilateral finger-nose-finger, heel-shin tests)
UN = Amputation or joint fusion, explain why untestable |
0 = Absent |
1 = Present in one limb |
2 = Present in two limbs |
- |
- |
8. Sensory (Sensation or grimace to pinprick when tested or withdraw from noxious stimuli in obtunded or aphasic patient) |
0 = Normal, no sensory loss |
1 = Mild-to-moderate sensory loss, less sharp or is dull in affected side, or loss of superficial pain but aware of touch) |
2 = Severe or total sensory loss, not aware of being touched in face, arm, and leg |
- |
- |
9. Best Language |
0 = No aphasia, normal |
1 = Mild-to-moderate aphasia, obvious loss of fluency or comprehension, without limitation on ideas expressed or form of expression. Reduced speech and/or comprehension however makes conversation about materials difficult |
2 = Severe aphasia, all communication is fragmentary expression, great need for inference, questioning, and guessing by listener. Examiner carries conversation. |
3 = Mute, global aphasia, no usable speech or auditory comprehension |
- |
10. Dysarthria
UN = Intubated or physical barrier |
0 = Normal |
1 = Mild-to-moderate dysarthria, slurs at least some words but at worst continues to be understood |
2 = Severe dysarthria, such slurring of speech that it is unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric |
- |
- |
11. Extinction and Inattention |
0 = No abnormality |
1 = Visual, tactile, auditory, spatial, or personal inattention, or extinction to bilateral simultaneous stimulation in one of the sensory modalities |
2 = Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space |
- |
- |