Where and with whom does the patient currently live?

What is their baseline cognitive and functional status?

6 Cognitive Domains (DSM-V Neurocog Disorders Criteria)

Parkinsons, Alzheimers, or Vascular Dementia

Where does the patient currently reside: _______

Who assists the patient with ADLs (family, health aide, etc.): _______

Workup for treatable causes of Memory Impairment

Duration and frequency of abortive agents used: _______

Tylenol/NSAIDS >15 d/mo and triptans >10 d/mo increase risk of medication overuse HA

Systemic conditions (Increased risk for secondary HA)

Systemic signs (meningitis, temporal arteritis, malignancy)

Associated symptoms that increase risk for secondary HA

CTA/MRA/DCA shows "string and beads" appearance

Complications: ischemic or hemorrhagic strokes

Associated with recent minor trauma (MVA, chiropractor)

Can have Horner syndrome or pulsitile tinnitus

Associated with OCPs, pregnancy and the puerperium, malignancy, infection, head injury and mechanical precipitants

Improve sensitivity and detect subtle peripheral lesions than T2

Showing cortical lesions to be more common than once thought by T2 imaging

Reflects disruption of the blood-brain barrier

Can be present after administration of gadolinium

Petechial and large parenchymal hemorrhages

Screen for previous episodes not recognized as seizures

Seizure Rescue Plan or Rescue Medications

Number of seizures without return to baseline

Received any of the following meds (MG exacerbation)

Recently started medications known to exacerbate MG

NOTE: if patient on high dose daily pyridostigmine (>120mg q3h), perform SLUDGE cholinergic crisis screen

IF YES, evaluate for ipsilateral CN6 involvement (Pontine lesion)

House-Brackmann scale of severity of facial nerve dysfunction

Eye: complete closure with minimal effort

Gross: obvious weakness and/or disfiguring asymmetry

Gross: barely perceptible motion/asymmetry at rest

Medication changes made last visit: _______

Are memory symptoms present? If yes, has pt had a workup for treatable causes of memory impairment?

Duration of symptoms (must be at least 24hr)

Date of last known pseudo-relapse: _______

Nutritional (deficiencies of B1, B12, copper, folate, vitamin E)

NOTE: BPPV may have feelings of constant dizziness if moving or in motion, but it should resolve when the patient is completely motionless

IF YES: Check orthostatic vitals and perform Dix-Hallpike

IF YES: do HINTS+ to differentiate between posterior circulation stroke and vestibular neuritis. Check if prior brain and/or vessel imaging

Signs/Symptoms Indicating Orthostatic Hypotension

Other Signs/Symptoms Indicating Autonomic Dysfunction

Conservative measures tried for orthostatic hypotension

Pharmacologic treatments tried for orthostatic hypotension

Medication toxicity causing orthostatic hypotension

Medication toxicity causing small fiber neuropathy

Small fiber neuropathy-associated conditions

Paraneoplastic/Autoimmune Autonomic Ganglionopathy

If any of the above checked, do Parkinsonism screen:

Screen for other causes of Memory Impairment

Screen for other causes of Gait Impairment

Neuro History Navigator

Altered Mental Status

Headache

Seizure

Weakness

Parkinsonism Features

Demyelinating

Other