Dr. Wasif Rizwan Malik

MBBS · FCPS (Neurosurgery) · Consultant Neurosurgeon & Brain–Spine Surgeon

Faraz Hospital, Dubai Mahal Chowk, Bahawalpur  |  0622885604  |  wasif.malik@gmail.com
Senior Registrar Neurosurgery, Bahawal Victoria Hospital (BVH), Bahawalpur

Brain ProformaNeurosurgical Evaluation

Date: _____ / _____ / _______
Ref No: ________________
Referring Physician: _____________

📋 Chief Complaint & History of Presenting Illness
🚨 Red Flag / Emergency Symptoms
🧠 Headache Characterization (If Applicable)
0
1
2
3
4
5
6
7
8
9
10
⚡ Seizure History
📊 GCS & Vital Signs
Glasgow Coma Scale
Eye Opening (E)
1
2
3
4
= __
Verbal Response (V)
1
2
3
4
5
= __
Motor Response (M)
1
2
3
4
5
6
= __
Total GCS Score:
__ / 15
Right: ___ mm  
Left: ___ mm  
🧠 Cranial Nerve Examination
CNNameTestRightLeftRemarks
IOlfactorySmell
IIOpticVA / VF / Fundus
III / IV / VIOculomotor/Trochlear/AbducensEOM / Diplopia / Ptosis / Nystagmus
VTrigeminalFacial sensation / Corneal reflex / Jaw
VIIFacialFacial movement (UMN vs LMN)
VIIIVestibulocochlearHearing / Rinne / Weber
IX / XGlossopharyngeal / VagusGag reflex / Palate / Voice
XIAccessorySCM / Trapezius power
XIIHypoglossalTongue deviation / Fasciculations
🩺 Motor / Sensory / Cerebellar / Meningeal Examination
Motor Examination
R Arm
L Arm
R Leg
L Leg
Sensory Examination
Cerebellar Examination
Meningeal Signs
Higher Mental Functions / Cognitive
📂 Past History / Medications
🔬 Investigations
Neuroimaging
Lab Investigations
Imaging Summary
✅ Working Diagnosis & Management Plan
Primary Diagnosis
ICD / Location / Laterality
Management Plan
Protocol By: Dr. Wasif Rizwan Malik | MBBS, FCPS Neurosurgery | Faraz Hospital, BVH Bahawalpur BRAIN EVALUATION PROFORMA  |  Signature: ____________________