| ☐ ☐ Peripheral neuropathy Pattern:……………………………………………………………. ☐ ☐ Distal diabetic sensory peripheral neuropathy ☐ ☐ Carpal Tunnel Syndrome ☐ ☐ Axonal Sensory Motor Neuropathy ☐ ☐ CIDP |
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| ☐ ☐ Myasthenia Gravis (MG) |
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| ☐ ☐ cerebellar syndromes Aetiology: ............................................................................................... |
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| ☐ ☐ Muscular dystrophy Aetiology: ............................................................................................... |
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| ☐ ☐ Vertigo and other vestibular disorders Aetiology: ............................................................................................... |
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| ☐ ☐ Space occupying lesions ☐ ☐ Primary ☐ ☐ Secondary neoplasms ☐ ☐ Granulomas ☐ ☐ Abscesses ☐ ☐ Spinal metastasis |
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| ☐ ☐ Central nervous system infections, ☐ ☐ Meningitis ☐ ☐ Encephalitis ☐ ☐ Empyema ☐ ☐ Pott’s disease ☐ ☐ Leprosy |
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| ☐ ☐ Idiopathic intracranial hypertension |
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| ☐ ☐ NPH |
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| ☐ ☐ Hearing loss |
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| ☐ ☐ Benign Hereditary Chorea |
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| ☐ ☐ Sleep paralysis |
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| ☐ ☐ Lightheaded on standing |
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| ☐ ☐ Paget’s disease of bone |
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| ☐ ☐ Systemic lupus erythematosus (SLE) |
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| ☐ ☐ Rheumatoid Arthritis (RA) |
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| ☐ ☐ Temporal arteritis (GCA) |
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| ☐ ☐ The post-traumatic disorders |
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| ☐ ☐ Conversion syndrome |
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| ☐ ☐ Hyperactivity attention deficit disorder HAAD |
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| ☐ ☐ Anxiety |
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| ☐ ☐ Cerebral palsy |
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| ☐ ☐ Stiff person syndrome |
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| ☐ ☐ Other |
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| State: |
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