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Practice name: ______________________________
Stroke Assessment (NIH Stroke Scale)
Your information
Full Name *
Symptom Onset / Last Known Well
Level of Consciousness
LOC Questions (Orientation)
LOC Commands
Visual Fields
Motor Arm (Left/Right)
Additional details
Motor Leg (Left/Right)
Sensory
Extinction/Inattention
Examiner Signature
Date
Stroke Assessment (NIH Stroke Scale) template from formisoft.com. formisoft.com/intake-templates/stroke-assessment