- Assess Level of Consciousness (0-3 points)
- Alert: 0
- Alerts to voice: 1
- Alerts to pain: 2
- Unresponsive: 3
- Assess Orientation (0-2 points)
- Current Month (1 point if fails)
- Patient’s own Age (1 point if fails)
- Follow Commands (0-2 points)
- Open and close eyes (1 point if fails)
- Make fist and release (1 point if fails)
- Follow my finger (0-2 points)
- Normal: 0
- Partial gaze palsy: 1
- Forced deviation: 2
- Visual field (0-3 points)
- No visual loss: 0
- Partial Hemianopsia: 1
- Complete Hemianopsia: 2
- Bilateral Hemianopsia: 3
- Facial palsy (0-3 points)
- Testing: Show teeth, Raise eyebrows, Squeeze eyes shut
- Normal symmetric movements: 0
- Minor paralysis: 1
- Partial paralysis: 2
- Complete paralysis: 3
- Motor: Left Arm (0-4 points)
- Testing: Elevation limb to 90 degrees for 10 seconds
- No drift: 0
- Drifts (within 10 seconds): 1
- Unable to get to and maintain full limb elevation: 2
- Unable to move against gravity (limb falls): 3
- No movement: 4
- Motor: Right Arm (0-4 points)
- Testing: Elevation limb to 90 degrees for 10 seconds
- No drift: 0
- Drifts (within 10 seconds): 1
- Unable to get to and maintain full limb elevation: 2
- Unable to move against gravity (limb falls): 3
- No movement: 4
- Motor: Left Leg (0-4 points)
- Testing: Elevation limb to 30 degrees for 5 seconds
- No drift: 0
- Drifts (within 5 seconds): 1
- Unable to get to and maintain full limb elevation: 2
- Unable to move against gravity (limb falls): 3
- No movement: 4
- Motor: Right Leg (0-4 points)
- Testing: Elevation limb to 30 degrees for 5 seconds
- No drift: 0
- Drifts (within 5 seconds): 1
- Unable to get to and maintain full limb elevation: 2
- Unable to move against gravity (limb falls): 3
- No movement: 4
- Coordination or limb Ataxia (0-2 points)
- Testing: Finger-Nose-Finger, Heel-knee-shin
- Absent: 0
- Present in one limb: 1
- Present in both limbs: 2
- Sensory (0-2 points)
- Test: Pin prick to face, arm, trunk, and legs
- Normal: 0
- Mild to moderate sensory loss (reduced, dull): 1
- Severe or total sensory loss (unaware of touch): 2
- Aphasia or Best Language (0-3 points)
- Test: Name items, Describe picture, Read sentences
- No Aphasia: 0
- Mild to moderate Aphasia: 1
- Severe Aphasia: 2
- Global Aphasia (Mute): 3
- Dysarthria (0-2 points)
- Normal articulation: 0
- Mild to moderate Dysarthria: 1
- Severe Dysarthria (nearly unintelligible): 2
- Intubated or other physical barrier: N/A
- Extinction and Inattention or Neglect (0-2 points)
- Testing: Bilateral simultaneous stimulation using one or more sensory modalities (vision, touch, hearing)
- No abnormality: 0
- Inattention or extinction to single sensory modality: 1
- Profound inattention or extinction or to multiple sensory modalities: 2
Related