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1a. Level of consciousness |
0 = Alert and responsive
1 = Arousable to minor stimulation
2 = Arousable only to painful stimulation
3 = Unarousable or reflex responses |
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1b. Questions
Ask patient's age and month. Must be exact. |
0 = Both correct
1 = One correct
2 = Neither correct |
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1c. Commands
Ask patient to open/close eyes, grip and release non-paretic hand. |
0 = Both correct
1 = One correct
2 = Neither correct |
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2. Best gaze
Horizontal extraocular movements by voluntary or reflexive (oculocephalic maneuver) testing. |
0 = Normal
1 = Partial gaze palsy; abnormal gaze in one or both eyes
2 = Forced eye deviation or total paresis which cannot be overcome by oculocephalic maneuver |
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3. Visual fields
Test by confrontation or threat as appropriate. If monocular, score field of good eye. |
0 = No visual loss
1 = Partial hemianopia, quadrantanopia, extinction
2 = Complete hemianopia
3 = Bilateral hemianopia or blindness |
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4. Facial palsy
If stuporous, check symmetry of grimace to pain. Paralysis (lower face). |
0 = Normal
1 = Minor paralysis (normal looking face, asymmetric smile)
2 = Partial paralysis
3 = Complete paralysis (upper and lower face) |
|
5a. Left motor arm
5b. Right motor arm
Arms outstretched 90° (if patient is sitting) or 45° (if supine) for 10 seconds. Encourage best effort, note paretic side. |
0 = No drift
1 = Drift but does not hit bed
2 = Some antigravity effort, but cannot sustain
3 = No antigravity effort, but minimal movement present
4 = No movement at all
X = Unable to assess due to amputation, fusion, etc |
|
6a. Left motor leg
6b. Right motor leg
Raise leg to 30° (always test patient supine) for 5 seconds. |
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7. Limb ataxia
Check finger-nose-finger; heel-shin; score only if out of proportion to weakness. |
0 = No ataxia (or aphasic, hemiplegic)
1 = Ataxia present in one limb
2 = Ataxia present in two limbs
X = Unable to assess as above |
|
8. Sensory
Use safety pin. Check grimace or withdrawal if stuporous. Score only stroke related losses. |
0 = Normal
1 = Mild to moderate unilateral sensory loss but patient aware of touch
2 = Severe to total sensory loss, patient unaware of touch (or bilateral sensory loss or comatose) |
|
9. Best language
Ask patient to describe cookie jar picture, name objects, read sentences. May use repeating, writing, stereognosis. |
0 = Normal
1 = Mild-moderate aphasia
2 = Severe aphasia (almost no information exchanged)
3 = Mute, global aphasia, or coma |
|
10. Dysarthria
Ask patient to read or repeat a list of words. |
0 = Normal
1 = Mild-moderate dysarthria
2 = Severe, unintelligible or mute
X = Intubation or mechanical barrier |
|
11. Extinction and inattention
Simultaneously touch patient on both hands, show fingers in both visual fields, ask patient to describe deficit, left hand. |
0 = Normal, none detected (or severe visual loss with normal cutaneous responses)
1 = Neglects or extinguishes to bilateral simultaneous stimulation in any sensory modality (visual, tactile, auditory, spatial, or personal inattention)
2 = Profound hemi-inattention or extinction in more than one modality |
