Templates › Forms › SEO page

Run: Spinal Cord Injury ASIA Exam Documentation

Document the motor, sensory, and sacral exam findings needed to assign an ASIA Impairment Scale grade and neurological level after spinal cord injury. Use it...

Fill this out, get a PDF emailed to you. No account required. Want to run it with your team and track results? Sign up free →

Exam Context

Exam Date (required)

Exam Time (required)

Exam Type (required)

Injury Context (required)

Briefly describe the known or suspected spinal cord injury context and relevant clinical situation.

Exam Performed By (required)

Clinician name and credentials.

Patient Consent / Disclosure (required)

Yes No N/A

Motor Examination

Motor Exam Completed (required)

Right Upper Extremity Motor Score

Enter the summed motor score for the right upper extremity when applicable.

Left Upper Extremity Motor Score

Enter the summed motor score for the left upper extremity when applicable.

Right Lower Extremity Motor Score

Enter the summed motor score for the right lower extremity when applicable.

Left Lower Extremity Motor Score

Enter the summed motor score for the left lower extremity when applicable.

Motor Exam Notes

Document key asymmetries, pain-limited effort, or other factors affecting interpretation.

Sensory Examination

Sensory Exam Completed (required)

Light Touch Status

Pin Prick Status

Right Sensory Level

Document the most caudal intact sensory level on the right, if determined.

Left Sensory Level

Document the most caudal intact sensory level on the left, if determined.

Sensory Exam Notes

Include any exam limitations, inconsistent responses, or factors affecting reliability.

Sacral Sparing and Anal Examination

Sacral Sparing Present (required)

Deep Anal Pressure

Voluntary Anal Contraction

Anal Exam Notes

Document patient tolerance, exam limitations, or reasons the exam could not be completed.

Classification and Interpretation

Neurological Level of Injury (required)

Enter the determined neurological level of injury.

ASIA Impairment Scale Grade (required)

Classification Rationale (required)

Summarize the findings used to determine the neurological level and ASIA grade.

Baseline Established

Yes No N/A

Follow-Up and Submission

Follow-Up Plan

Document recommended repeat exam timing, specialist review, or rehabilitation follow-up.

Handoff Required (required)

Handoff Notes

Visible when a handoff is needed; include concise clinical summary for the receiving team.

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Generated with MangoApps Templates — browse 250+ free