Neurology — New Patient Consultation Template

Consultation Information

Referring physician: [Name, specialty]
Reason for referral: [Chief complaint]
Date of consultation: [Date]
Urgency: Routine / Urgent

Chief Complaint

[Primary neurological concern]
Duration: [Onset, timeline]
Laterality: Right / Left / Bilateral / N/A
Current status: Improving / Stable / Worsening / Fluctuating

History of Present Illness

[Detailed narrative of neurological complaint]

For Headache

Type: Migraine / Tension / Cluster / Other
Location: [Unilateral, bilateral, frontal, occipital, etc.]
Quality: Throbbing / Pressure / Stabbing / Dull
Severity: [X]/10
Duration: [Minutes, hours, days]
Frequency: [Episodes per week/month]
Aura: None / Visual / Sensory / Motor / [Description]
Triggers: [Stress, foods, sleep, menses, etc.]
Associated: Photophobia / Phonophobia / Nausea / Vomiting / Neck pain
Red flags: [ ] Thunderclap onset [ ] Fever [ ] Weight loss [ ] Worst headache of life [ ] Neurological deficits

For Seizure

Type: Generalized tonic-clonic / Absence / Focal aware / Focal impaired awareness / Unknown
Frequency: [Episodes per week/month/year]
Last seizure: [Date/time]
Duration: [Seconds/minutes]
Warning/aura: None / [Description]
Ictal features: [Movements, behaviors, speech]
Postictal state: [Confusion, weakness, duration]
Witnesses: Yes / No
Tongue bite: Yes / No
Incontinence: Yes / No
Triggers: [Sleep deprivation, alcohol, stress, flashing lights]
Driving status: [Restrictions]

For Weakness/Numbness

Onset: Sudden / Gradual
Pattern: [Distribution - single limb, hemiparesis, paraparesis, etc.]
Progression: Stable / Progressive / Fluctuating / Improving
Associated: Pain / Paresthesias / Bowel/bladder changes / Dysphagia / Dysarthria

For Movement Disorder

Type: Tremor / Bradykinesia / Rigidity / Dystonia / Chorea / Tics
Onset: [Date]
Progression: Stable / Progressive
Rest vs action: [When symptoms occur]
Asymmetry: Yes / No
Associated: Gait changes / Falls / Cognitive changes / Sleep disturbance

For Cognitive Concerns

Domains affected: Memory / Language / Executive function / Visuospatial
Onset: Sudden / Gradual
Progression: Stable / Progressive / Fluctuating
Functional impact: [ADLs, IADLs]
Behavioral changes: None / [Depression, anxiety, apathy, disinhibition]
Caregiver input: [Observations]

Neurological Review of Systems

[ ] Headaches [ ] Vision changes [ ] Diplopia [ ] Hearing changes
[ ] Vertigo/dizziness [ ] Facial weakness [ ] Dysphagia [ ] Dysarthria
[ ] Weakness [ ] Numbness/paresthesias [ ] Tremor [ ] Gait difficulty
[ ] Incoordination [ ] Memory problems [ ] Confusion [ ] Seizures
[ ] Sleep disturbance [ ] Bladder/bowel dysfunction

Past Medical History

Neurological conditions:

• Stroke/TIA: None / [Date, type, deficits]
• Seizures/epilepsy: None / [Type, onset, medications]
• Head injury: None / [Date, severity, LOC]
• CNS infection: None / [Type, date]
• Brain surgery: None / [Procedure, date]
• MS/demyelinating: None / [Details]
• Parkinson's/movement: None / [Details]

Other medical conditions: [Relevant comorbidities]

Surgical History

[Relevant surgeries, especially neurosurgical]

Medications

Current neurological medications:

• [Medication, dose, frequency, duration]

Prior failed medications: [If applicable]
Other medications: [List]

Allergies

[Drug allergies with reactions]

Family History

Migraines: Yes / No — [Relationship]
Epilepsy: Yes / No — [Relationship]
Stroke: Yes / No — [Relationship, age]
Dementia: Yes / No — [Type, relationship]
Movement disorders: Yes / No — [Type, relationship]
Neuromuscular disease: Yes / No — [Type, relationship]
Other neurological: [Details]

Social History

Occupation: [Current, cognitive/physical demands]
Education: [Highest level completed]
Handedness: Right / Left / Ambidextrous
Tobacco: Current / Former / Never — Pack-years: [X]
Alcohol: [Quantity, frequency]
Recreational drugs: [If applicable]
Driving: Active / Restricted / Not driving
Living situation: Independent / With family / Assisted living / SNF
ADL/IADL status: Independent / Needs assistance with [X]

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
RR: [X]
Temp: [X]°F
SpO2: [X]%

General

Appearance: Well-appearing / [Concerns]
Affect: Normal / [Flat, anxious, depressed]

Mental Status

Alertness: Alert / Drowsy / Lethargic / Obtunded
Orientation: Oriented x [1/2/3/4] — [Person, place, time, situation]
Attention: Intact / Impaired — [Months backward, serial 7s]
Language:

• Fluency: Normal / Non-fluent
• Comprehension: Intact / Impaired
• Repetition: Intact / Impaired
• Naming: Intact / Impaired — [Objects tested]

Memory:

• Immediate recall: [X]/3 words
• Delayed recall: [X]/3 words at 5 minutes
• Remote: Intact / Impaired

Executive function: [Clock draw, Luria, trails description]
Visuospatial: Intact / Impaired — [Copy, neglect testing]

Cranial Nerves

I (Olfactory): Not tested / Intact / Impaired
II (Optic):

• Visual acuity: [R: 20/X, L: 20/X]
• Visual fields: Full / [Deficit — type, location]
• Fundoscopy: Normal / [Papilledema, pallor, hemorrhage]
• Pupils: [Size] mm, PERRL / [Anisocoria, APD]

III, IV, VI (Oculomotor):

• Extraocular movements: Full / [Limitation — specify]
• Ptosis: Absent / Present [R/L]
• Nystagmus: Absent / Present — [Direction, type]

V (Trigeminal):

• Sensation: Intact V1/V2/V3 / [Deficit]
• Motor (masseter): Intact / Weak [R/L]
• Corneal reflex: Present / Absent [R/L]

VII (Facial):

• Motor: Symmetric / [Weakness — upper vs lower, R/L]
• Taste: Not tested / Intact / Impaired

VIII (Vestibulocochlear):

• Hearing: Intact bilaterally / [Decreased R/L]
• Rinne/Weber: [If tested]

IX, X (Glossopharyngeal, Vagus):

• Palate elevation: Symmetric / Asymmetric
• Gag reflex: Present / Absent / Diminished
• Voice: Normal / Hoarse / Nasal

XI (Accessory):

• SCM: [5]/5 bilaterally
• Trapezius: [5]/5 bilaterally

XII (Hypoglossal):

• Tongue: Midline / Deviation [R/L]
• Atrophy: Absent / Present
• Fasciculations: Absent / Present

Motor Examination

Bulk: Normal / Atrophy [Location]
Tone: Normal / Increased [Spastic/rigid] / Decreased [Location]
Strength (0-5 scale):

	Right	Left
Deltoid	/5	/5
Biceps	/5	/5
Triceps	/5	/5
Wrist extension	/5	/5
Grip	/5	/5
Finger abduction	/5	/5
Hip flexion	/5	/5
Knee extension	/5	/5
Knee flexion	/5	/5
Ankle dorsiflexion	/5	/5
Ankle plantarflexion	/5	/5
Great toe extension	/5	/5

Pattern: Normal / Pyramidal / LMN / Myopathic / [Other]
Pronator drift: Absent / Present [R/L]
Fasciculations: Absent / Present [Location]

Sensory Examination

Light touch: Intact / [Deficit — distribution]
Pinprick: Intact / [Deficit — distribution]
Temperature: Not tested / Intact / [Deficit]
Vibration: Intact / [Decreased — level]
Proprioception: Intact / [Impaired — specify]
Romberg: Negative / Positive
Sensory level: None / [Level]
Pattern: Normal / Stocking-glove / Dermatomal / Hemisensory / [Other]

Reflexes (0-4+)

	Right	Left
Biceps (C5-6)
Brachioradialis (C6)
Triceps (C7)
Patellar (L4)
Achilles (S1)

Plantar response: Flexor / Extensor [R/L]
Hoffman's sign: Absent / Present [R/L]
Clonus: Absent / Present [Location, beats]

Coordination

Finger-to-nose: Normal / Dysmetria / Intention tremor [R/L]
Heel-to-shin: Normal / Dysmetria [R/L]
Rapid alternating movements: Normal / Dysdiadochokinesia [R/L]

Gait and Station

Gait: Normal / [Wide-based, spastic, ataxic, shuffling, festinating, steppage, antalgic]
Tandem gait: Normal / Impaired
Toe walking: Normal / Impaired
Heel walking: Normal / Impaired
Romberg: Negative / Positive
Pull test (if applicable): Normal / Retropulsion

Special Tests (if indicated)

Meningeal signs:

• Neck stiffness: Absent / Present
• Kernig: Negative / Positive
• Brudzinski: Negative / Positive

Diagnostic Studies Review

Prior imaging:

• MRI brain: [Date, findings]
• MRI spine: [Date, findings]
• CT head: [Date, findings]
• MRA/CTA: [Date, findings]

Prior studies:

• EEG: [Date, findings]
• EMG/NCS: [Date, findings]
• Lumbar puncture: [Date, findings]
• Evoked potentials: [Date, findings]

Laboratory: [Relevant results]

Assessment

1) [Primary neurological diagnosis]
[Localization, etiology if known]
2) [Secondary diagnoses]
Differential diagnosis:

• [Most likely]
• [Alternative 1]
• [Alternative 2]

Localization: [Cortical, subcortical, brainstem, spinal cord, peripheral nerve, NMJ, muscle]

Plan

Diagnostic Workup

Imaging:

• [ ] MRI brain [With/without contrast]
• [ ] MRI spine [Cervical/thoracic/lumbar]
• [ ] MRA/CTA [Head/neck]
• [ ] CT head

Neurophysiology:

• [ ] EEG [Routine/extended/video]
• [ ] EMG/NCS
• [ ] Evoked potentials [Type]

Laboratory:

• [ ] [Specific tests based on differential]

Lumbar puncture: [ ] Indicated — [Opening pressure, cell count, protein, glucose, cultures, cytology, etc.]

Treatment

Acute management: [If applicable]
Medications:

• [New medication, dose, titration schedule]
• [Adjustments to current medications]

Referrals

• [ ] Neuropsychology
• [ ] Physical therapy
• [ ] Occupational therapy
• [ ] Speech therapy
• [ ] Neuro-ophthalmology
• [ ] Neurosurgery
• [ ] Sleep medicine
• [ ] Other: [Specify]

Patient Education

• Diagnosis explanation
• Medication instructions and side effects
• Driving restrictions (if applicable)
• Seizure precautions (if applicable)
• Activity restrictions
• Warning signs requiring urgent evaluation

Follow-up

Return: [X] weeks

• Sooner if: [Specific warning signs]
• For: [Results review, treatment response, etc.]

Communication

Discussed with patient/family: [Topics covered]
Report sent to: [Referring physician, PCP]