15 - Welcome | NINDS Common Data Elements



Section 1: Vital MeasurementsSTAFF ID:__ __ __Supine measurementsBlood pressure (mmHg)Heart RateRespiratory Rate/Systolicdiastolicbeats/minbreaths/minPlease specify how many minutesStanding for __ __ minutes Blood pressure (mmHg)Heart RateRespiratory Rate/Systolicdiastolicbeats/minbreaths/minOral Temperature: .FWeight: . lbs. Height: ft.. in. Neck Circumference: in.Waist Circumference: in. Hip Circumference: in. Physical examinationCommentsIf abnormal, explain or describe below1.HeadNormalAlopeciaHair1 FORMCHECKBOX 2 FORMCHECKBOX NormalAbnormalScalp1 FORMCHECKBOX 2 FORMCHECKBOX Head summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 2.Oral cavityAbsentPresentMercury fillings1 FORMCHECKBOX 2 FORMCHECKBOX GoodPoorEdentulousDentition1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX GoodFairPoor Gums1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX NormalAbnormalOropharynx1 FORMCHECKBOX 2 FORMCHECKBOX Oral status summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 3.NeckYesNoSupple1 FORMCHECKBOX 2 FORMCHECKBOX NoYesMasses1 FORMCHECKBOX 2 FORMCHECKBOX Jugular venousAbsentPresentDistension1 FORMCHECKBOX 2 FORMCHECKBOX Neck summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 4.ThyroidNoYesVisible1 FORMCHECKBOX 2 FORMCHECKBOX Palpable1 FORMCHECKBOX 2 FORMCHECKBOX Nodules1 FORMCHECKBOX 2 FORMCHECKBOX Size 1 FORMCHECKBOX 2 FORMCHECKBOX Thyroid summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 5.EyesPupilsYesNoEqual1 FORMCHECKBOX 2 FORMCHECKBOX Round1 FORMCHECKBOX 2 FORMCHECKBOX Reactive1 FORMCHECKBOX 2 FORMCHECKBOX Accommodate1 FORMCHECKBOX 2 FORMCHECKBOX NormalIctericOtherSclera1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX NormalAbnormalFundoscopic1 FORMCHECKBOX 2 FORMCHECKBOX Photophobia 1 FORMCHECKBOX 2 FORMCHECKBOX Eyes summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 6.EarsNormalAbnormalTympanic membrane1 FORMCHECKBOX 2 FORMCHECKBOX Canals1 FORMCHECKBOX 2 FORMCHECKBOX Ears summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 7.NoseNormalAbnormalNasal mucosa1 FORMCHECKBOX 2 FORMCHECKBOX Nose summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 8. Pharynx Normal Abnormal Mucosa 1 FORMCHECKBOX 2 FORMCHECKBOX Volume adequate 1 FORMCHECKBOX 2 FORMCHECKBOX Tongue large 1 FORMCHECKBOX 2 FORMCHECKBOX TMJ tender 1 FORMCHECKBOX 2 FORMCHECKBOX Pharynx summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 9.ChestNormalAbnormalShape1 FORMCHECKBOX 2 FORMCHECKBOX Chest summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 10.LungsNormalAbnormalChest percussion1 FORMCHECKBOX 2 FORMCHECKBOX Lung auscultation(sound, rales, crepitations) 1 FORMCHECKBOX 2 FORMCHECKBOX Lungs summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 11.Heart and large arteriesNormalAbnormalHeart palpation1 FORMCHECKBOX 2 FORMCHECKBOX Heart auscultation(rate, rhythm, murmurs, extra sounds) 1 FORMCHECKBOX 2 FORMCHECKBOX Carotid artery Auscultation/PainAbsentPresent(systolic bruit)1 FORMCHECKBOX 2 FORMCHECKBOX Abdominal artery auscultation (bruit)1 FORMCHECKBOX 2 FORMCHECKBOX Heart and large arteries summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 12a.AbdomenNormalAbnormalBowel Sounds1 FORMCHECKBOX 2 FORMCHECKBOX NoYesTenderness1 FORMCHECKBOX 2 FORMCHECKBOX Masses1 FORMCHECKBOX 2 FORMCHECKBOX Abdomen summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 12b.LiverNoYesPalpable1 FORMCHECKBOX 2 FORMCHECKBOX If palpable, describe hereLiver summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 12c.SpleenNoYesPalpable1 FORMCHECKBOX 2 FORMCHECKBOX If palpable, describe hereSpleen summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 13.Extremities NoYesEdematous1 FORMCHECKBOX 2 FORMCHECKBOX Dependent rubor 1 FORMCHECKBOX 2 FORMCHECKBOX PulsesLeftRightRadialFemoralTibial art. or dorsalis pedis arteryExtremities summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 14.Joints Muscles ( review swelling, heat or redness, nodularity, ROM, extensiblity, tender points)NormalAbnormalSpine1 FORMCHECKBOX 2 FORMCHECKBOX Shoulders1 FORMCHECKBOX 2 FORMCHECKBOX Elbows1 FORMCHECKBOX 2 FORMCHECKBOX Wrists1 FORMCHECKBOX 2 FORMCHECKBOX Hands1 FORMCHECKBOX 2 FORMCHECKBOX Hips1 FORMCHECKBOX 2 FORMCHECKBOX Knees1 FORMCHECKBOX 2 FORMCHECKBOX Ankles1 FORMCHECKBOX 2 FORMCHECKBOX Feet1 FORMCHECKBOX 2 FORMCHECKBOX Joints and muscles summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 15.SkinAbsentPresentJaundice1 FORMCHECKBOX 2 FORMCHECKBOX Acne1 FORMCHECKBOX 2 FORMCHECKBOX Ulcerations1 FORMCHECKBOX 2 FORMCHECKBOX Rash1 FORMCHECKBOX 2 FORMCHECKBOX Lesions1 FORMCHECKBOX 2 FORMCHECKBOX Too dry1 FORMCHECKBOX 2 FORMCHECKBOX Skin summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 16.Lymph NodesCervicalNormalEnlargedTenderPosterior1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX Anterior1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX Supraclavicular1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX Axillary1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX Inguinal1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX Note if supraclavicular fullness present.Lymph nodes summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 17.Neurologic17a.CerebellarNormalAbnormalFinger-Nose-Finger1 FORMCHECKBOX 2 FORMCHECKBOX Gait1 FORMCHECKBOX 2 FORMCHECKBOX Heel to shin1 FORMCHECKBOX 2 FORMCHECKBOX Tandem stance/gait1 FORMCHECKBOX 2 FORMCHECKBOX with augmentation 1 FORMCHECKBOX 2 FORMCHECKBOX NegativePositiveRomberg1 FORMCHECKBOX 2 FORMCHECKBOX Handedness Right hand Left hand Both hands 1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX Cerebellar summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 17b.Cranial NervesNormalAbnormalVisual fields(confrontation)1 FORMCHECKBOX 2 FORMCHECKBOX Shoulder raise1 FORMCHECKBOX 2 FORMCHECKBOX Hearing (gross)1 FORMCHECKBOX 2 FORMCHECKBOX Extra ocular muscles1 FORMCHECKBOX 2 FORMCHECKBOX Facial expression1 FORMCHECKBOX 2 FORMCHECKBOX Cranial nerves summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 17c.Sensory (hands, feet)NormalAbnormalLight touch1 FORMCHECKBOX 2 FORMCHECKBOX Pinprick1 FORMCHECKBOX 2 FORMCHECKBOX Vibration1 FORMCHECKBOX 2 FORMCHECKBOX Proprioception(great toe, up/down1 FORMCHECKBOX 2 FORMCHECKBOX Sensory (hands, feet) summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 17d.Muscles NormalAbnormalTone1 FORMCHECKBOX 2 FORMCHECKBOX Atrophy 1 FORMCHECKBOX 2 FORMCHECKBOX Rise from chair totip toes1 FORMCHECKBOX 2 FORMCHECKBOX AbsentPresentInvoluntary movements1 FORMCHECKBOX 2 FORMCHECKBOX Proximal muscle strength Normal Abnormal 1 FORMCHECKBOX 2 FORMCHECKBOX Distal muscle strength Normal Abnormal 1 FORMCHECKBOX 2 FORMCHECKBOX Muscle strength summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 17e.ReflexesNormalAbnormalHyperBiceps1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX Triceps1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX Patellar1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX Ankle Jerk1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX Absent PresentBabinski1 FORMCHECKBOX 2 FORMCHECKBOX Reflexes summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX Neurologic summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 18.Mental and Psychological StatusNormalAbnormalAffect1 FORMCHECKBOX 2 FORMCHECKBOX Speech1 FORMCHECKBOX 2 FORMCHECKBOX Orientation............................. 1 FORMCHECKBOX 2 FORMCHECKBOX Thoughts............................. 1 FORMCHECKBOX 2 FORMCHECKBOX Mental/Psychological status summaryNormalAbnormalExam not done1 FORMCHECKBOX 2 FORMCHECKBOX 3 FORMCHECKBOX 19. Other (specify)Mental status Normal Abnormal 1 FORMCHECKBOX 2 FORMCHECKBOX 20. Other (specify)21. Other (specify)Section 4: Clinical Impressions/ Differential DiagnosesImpression: Overall impression of this patient [Mental status, physical condition, over - or underweight, age corresponding to calendar or not, systems with problems, etc. If you find anything abnormal -what differential diagnoses would you pursue should this be your (not a study) patient] ................
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