APPENDIX 5A — Neurological Examination Change A 5A-3 Figure 5A-1a.  Neurological Examination Checklist (sheet 1 of 2).   NEUROLOGICAL EXAMINATION CHECKLIST (Sheet 1 or 2) (See text of Appendix 5A for examination procedures and definitions of terms.) Patient’s Name: ____________________________________Date/Time: ____________________________ Describe pain/numbness: __________________________________________________________________ _______________________________________________________________________________________ HISTORY Type of dive last performed:  _________________  Depth:  _____________ How long: _________________ Number of dives in last 24 hours: ____________________________________________________________ Was symptom noticed before, during or after the dive?  ___________________________________________ If during, was it while descending, on the bottom or ascending? ____________________________________ Has symptom increased or decreased since it was first noticed? ____________________________________ Have any other symptoms occurred since the first one was noticed? _________________________________ Describe: _______________________________________________________________________________ Has patient ever had a similar symptom before? ___________________When: ________________________ ________________________________________________________________________________________ MENTAL STATUS/STATE OF CONSCIOUSNESS ________________________________________________________________________________________ ________________________________________________________________________________________ COORDINATION STRENGTH (Grade 0 to 5) Walk: _________ Heel-to Toe: _________ Romberg: _________ Finger-to-Nose: _________ Heel Shin Slide: _________ Rapid Movement: _________ CRANIAL NERVES Sense of Smell (I): ________ Vision/Visual Fld (II): _________ Eye Movements, Pupils (III, IV, VI): _________ Facial Sensation, Chewing (V): _________ Facial Expression Muscles (VI): _________ Hearing (VII): _________ Upper Mouth, Throat Sensation (IX): _________ Gag & Voice (X): _________ Shoulder Shrug (XI): _________ Tongue (XII): _________ UPPER BODY Deltoids L ____ R ____ Latissimus   L ____  R ____ Biceps   L ____  R ____ Triceps        L ____  R ____ Forearms   L ____  R ____ Hands   L  ____ R ____ LOWER BODY Hips Flexion       L ___    R ____ Extension     L ___    R ____ Abduction      L ___  R ____ Adduction     L ___   R ____ Knees Flexion     L ___  R ____ Extension     L ____ R ____