Observations:

CLOTHES

Condition:

  Disorderly      Disarranged      Soiled      Mussed       Orderly

BREATH

Odor of Alcoholic Beverage:

  Strong     Moderate      Faint      None

ATTITUDE

  Excited  Hilarious  Talkative  Carefree  Sleepy  Profanity  Combative 
Indifferent  Insulting  Cocky   Cooperative         Polite
    Other  

ACTIONS

Hiccupping    Belching    Vomiting      Fighting      Crying       Laughing

SPEECH

Not Understandable  Mumbled  Slurred  Mush Mouthed  Confused  Thick Tongued  Stuttered  Accent     Fair    Good      Other

Performance Tests:

WALK AND TURN

ONE LEG STAND

Moves feet to keep balance while listening to instructions

Moves feet to keep balance while listening to instructions

Starts before instructions completed

Starts before instructions completed

Stops while walking to steady self

Sways while balancing (before or during count)

Does not touch heel-to-toe

Raises arms 6” for balance

Raises arm more than 6” for balance

Hops

Steps off line while walking

Puts foot down     Approx. times

Turns incorrectly or loses balance while turning

Does not count out loud

Incorrect number of steps. Took# back#

Cannot count to thirty   stops at approx. number

Cannot do test (including steps offline 3 or more times)

Cannot do test (puts foot down 3 or more times)

Other:

Other:

Balance: Falls  Needs support Sways   Unsure

Balance: Falls  Needs support  Sways  Unsure

ALPHABET – STANDING WITH EYES CLOSED

HORIZONTAL GAZE NYSTAGMUS

Starts before instructions completed

Right Eye............................................................      Left Eye

Moves feet to keep balance

                        Lack of Smooth pursuit                      

Sways while balancing

           Distinct Nystagmus at maximum deviation  

Recites alphabet out of order

          Onset of nystagums before 45 degrees          

Leaves letters out of the alphabet

Moves feet to keep balance

Starts over from the beginning   No. of times

Sways during testing

Gets to letter   before scrambling letters

Does not keep hands on face

Cannot do test, says

Does not follow pen  

Other

Vertical nystagmus       

Finger to Nose:  Left: Sure Missed 
                              Right: Sure Missed

Eyes:  normal   watery   bloodshot    dilated
   Equal Pupil Size      Equal Tracking