Alert = 0
Not alert, arousable to mild stimulation = 1
Not alert, arousable to significant stimulation = 2
Not alert; reflexic, autonomic or no response = 3
Month and DOB
Both correct = 0
One correct = 1
Zero correct = 2
Both correct = 0
One correct = 1
Zero correct = 2
Open/close eyes & squeeze/release hand:
Both correct = 0
One correct = 1
Zero correct = 2
Both correct = 0
One correct = 1
Zero correct = 2
Horizontal voluntary or oculocephalic reflex:
Normal = 0
Partial gaze palsy = 1
Forced deviation or total gaze palsy = 2
Normal = 0
Partial gaze palsy = 1
Forced deviation or total gaze palsy = 2
Normal = 0
Partial hemianopia = 1
Complete hemianopia = 2
Bilateral hemianopia or cortical blindness = 3
Normal = 0
Minor, flat nasolabial fold = 1
Partial or total uni lower paralysis= 2
Complete paralysis 1 or both sides (upper & lower) = 3
10 seconds:
No drift = 0
Some drift = 1
Falls, effort against gravity = 2
Falls, No effort against gravity = 3
No movement = 4
No drift = 0
Some drift = 1
Falls, effort against gravity = 2
Falls, No effort against gravity = 3
No movement = 4
5 seconds:
No drift = 0
Some drift = 1
Falls, effort against gravity = 2
Falls, No effort against gravity = 3
No movement = 4
No drift = 0
Some drift = 1
Falls, effort against gravity = 2
Falls, No effort against gravity = 3
No movement = 4
Absent = 0
One limb = 1
Two limb = 2
Arms, legs, trunk:
Normal = 0
Present but altered = 1
Absent = 2
Normal = 0
Present but altered = 1
Absent = 2
Identification (picture or tactile), repetition, comprehension:
No aphasia = 0
Mild to moderate = 1
Severe = 2
Mute/Global aphasia = 3
No aphasia = 0
Mild to moderate = 1
Severe = 2
Mute/Global aphasia = 3
None = 0
Mild to moderate = 1
Severe = 2
Neglect:
None = 0
Loss of 1 modality (visual, tactile, auditory, spatial, personal) = 1
Profound hemi-inattention or more than 1 modality = 2
None = 0
Loss of 1 modality (visual, tactile, auditory, spatial, personal) = 1
Profound hemi-inattention or more than 1 modality = 2
NIH Stroke Scale
Modified Rankin Scale
AVPU scale
Glasgow Coma Scale
Mini mental status exam
Compartment pressure measurement
Glasgow-Blatchford Bleeding Score
SAD PERSONS score