Hammersmith Infant Neurologic Exam (HINE)

Form Approved

OMB No.0920-XXXX

Exp. Date xx/xx/20xx

Hammersmith Infant Neurological Exam (HINE)
Participant ID	_______________________
Name of Assessor	__________________(free type)
Name of Data Clerk	__________________(free type)
Date of assessment	______ (day – 2 digits) ______ (month – 2 digits) __________ (year – 4 digits)
Section 1: Nerve Function Posture Movements Tone Reflexes and Reactions	Facial Appearance Eye Appearance Auditory response Visual Response Sucking/Swallowing Head Trunk Arms Hands Legs Feet Movements Quantity Movements Quality Scarf Sign Passive Shoulder Elevation Pronation/Supination Abductors Popliteal Angle Ankle Dorsiflexion Pulled to Sit Ventral Suspension Tendon Reflexes Arm Protection Vertical Suspension Lateral Tilting Forward parachute	 3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0  3  2.5  2  1.5  1  0
Scores Section 1 Score	___________________ (2 digits)
Comments	______________________________________________ (free type)
*Note: if child’s Section 1 score is <52 (range: 0 – 78), they will receive the Evaluation of Cerebral Palsy

Evaluation of Cerebral Palsy
Participant ID		_______________________
Name of Assessor		__________________(free type)
Name of Data Clerk		__________________(free type)
Date of assessment		______ (day – 2 digits) ______ (month – 2 digits) __________ (year – 4 digits)
Spastic	 Yes  No If Yes, which limbs are affected? Symmetric or asymmetric? If asymmetric, left or right side more affected? If asymmetric, upper or lower extremities more affected?		 Right upper extremity  Left upper extremity  Right lower extremity  Left lower extremity  Symmetric  Asymmetric  Left  Right  Upper  Lower
Ataxic	 Yes  No If Yes, which limbs are affected? Symmetric or asymmetric? If asymmetric, left or right side more affected? If asymmetric, upper or lower extremities more affected?		 Right upper extremity  Left upper extremity  Right lower extremity  Left lower extremity  Symmetric  Asymmetric  Left  Right  Upper  Lower
Hypotonic	 Yes  No If Yes, which limbs are affected? Symmetric or asymmetric? If asymmetric, left or right side more affected? If asymmetric, upper or lower extremities more affected?		 Right upper extremity  Left upper extremity  Right lower extremity  Left lower extremity  Symmetric  Asymmetric  Left  Right  Upper  Lower
Athetoid	 Yes  No If Yes, which limbs are affected? Symmetric or asymmetric? If asymmetric, left or right side more affected? If asymmetric, upper or lower extremities more affected?		 Right upper extremity  Left upper extremity  Right lower extremity  Left lower extremity  Symmetric  Asymmetric  Left  Right  Upper  Lower
Dystonic	 Yes  No If Yes, which limbs are affected? Symmetric or asymmetric? If asymmetric, left or right side more affected? If asymmetric, upper or lower extremities more affected?		 Right upper extremity  Left upper extremity  Right lower extremity  Left lower extremity  Symmetric  Asymmetric  Left  Right  Upper  Lower
Mixed	 Yes  No If Yes, which limbs are affected? Symmetric or asymmetric? If asymmetric, left or right side more affected? If asymmetric, upper or lower extremities more affected?		 Right upper extremity  Left upper extremity  Right lower extremity  Left lower extremity  Symmetric  Asymmetric  Left  Right  Upper  Lower
Unspecified	 Yes  No If Yes, which limbs are affected? Symmetric or asymmetric? If asymmetric, left or right side more affected? If asymmetric, upper or lower extremities more affected?		 Right upper extremity  Left upper extremity  Right lower extremity  Left lower extremity  Symmetric  Asymmetric  Left  Right  Upper  Lower