Nama Pasien :................................................ Diagnosis :.....................................................................

Umur :................................................
NIHSS MRS / KRS :.....................................................................
TES DEFISIT RESPON NIHSS Masuk NIHSS Keluar

1.a. Derajad kesadaran Sadar[0]

Mengantuk[1]
Stupor[2]
Koma [3]
1.b Derajad kesadaran (menjawab pertanyaan) Menjwb. 2 pertanyaan tepat [0]
Menjwb. 1 pertanyaan tepat [1]
Salah [2]
1.c Derajad kesadaran (melaksanakan perintah) Mengikuti 2 perintah tepat [0]
Mengikuti 1 perintah tepat[1]
Salah [2]
2 Gerakan mata konjugat horisontal [GAZE] Normal [0]
Abnormal pd satu mata [1]
Abnormal pd kedua mata [2]
3 Lapang pandang pada tes konfrontasi Tak ada gangguan visual [0]
Hemianopia parsial [1]
Hemianopia komplit [2]
Hemianopia bilateral [3]
4. Kelumpuhan wajah Normal [0]
Minor [1]
Parsial [2]
Komplit [3]

5. Motorik lengan kanan Tak ada kelumpuhan [0]

Jatuh sebelum 10 detik [1]
Tdk dpt diluruskan scr penuh [2]
Tdk dpt menahan gravitasi [3]
Tdk ada gerakan [4]
5. Motorik lengan kiri Tak ada kelumpuhan [0]
Jatuh sebelum 10 detik [1]
Tdk dpt diluruskan scr penuh [2]
Tdk dpt menahan gravitasi [3]
Tdk ada gerakan [4]
6. Motorik tungkai kanan Tak ada kelumpuhan [0]
Jatuh sebelum 10 detik [1]
Tdk dpt diluruskan scr penuh [2]
Tdk dpt menahan gravitasi [3]
Tdk ada gerakan [4]
6. Motorik tungkai kiri Tak ada kelumpuhan [0]
Jatuh sebelum 10 detik [1]
Tdk dpt diluruskan scr penuh [2]
Tdk dpt menahan gravitasi [3]
Tdk ada gerakan [4]
7. Ataksia ekstremitas Tak ada [0]
Pd ekstremitas atas atau bawah [1]
Pada keduanya [2]
8. Sensorik Normal [0]
Parsial [1]
Terganggu berat [2]
9. Afasia Tak ada afasia [0]
Afasia ringan –sedang [1]
Afasia berat [2]
Bisu [3]
10. Disartria Normal [0]
Disatria ringan –sedang [1]
Distartria berat [2]
11. Neglect/inattention Normal[0]
Ringan [1]
Hebat [2]
TOTAL SKOR NIHSS

MODIFIED RANKIN SCALE (MRS) TOTAL (0–6) : …...................................................................(0)No symptoms at all (1) No significant disability despite
symptoms; able to carry out all usual duties and activities (2)Slight disability; unable to carry out all previous activities, but able to look after own affairs without
assistance (3)Moderate disability; requiring some help, but able to walk without assistance (4)Moderately severe disability; unable to walk without assistance and
unable to attend to own bodily needs without assistance(5)Severe disability; bedridden, incontinent and requiring constant nursing care and attention(6)Dead