Screening and Assessment Tools

Below is a list of screening tools and outcome measures taken from various stroke best practice resources.  For a comprehensive list of these tools, please refer to the Stroke Engine website.

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Acute Stroke Assessment Scales

• Canadian Neurological Scale (CNS)
• Charlson Comorbidity Index (CCI)
• Glasgow Coma Scale (GCS)
• Mini-Mental State Examination (MMSE)
• Montreal Cognitive Assessment (MoCA©)
• National Institutes of Health Stroke Scale (NIHSS)
• Orpington Prognostic Score (OPS) 

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Functional Assessment Scales

• AlphaFIM® Instrument – An abbreviated version of the FIM™. It is designed to assess disability and functional status to provide an objective estimate of burden of care in the acute care setting
• Barthel Index (BI) – A widely used measure of functional independence in the rehabilitation setting
• Berg Balance Scale (BBS) – This measure quantitatively assesses balance in older adults
• Chedoke-McMaster Stroke Assessment (CMSA) – An assessment that measures physical impairment and disability in clients with stroke and other neurological impairment.
• Functional Independence Measure (FIM™) –A widely used measure of function and burden of care, which reflects the minutes of care necessary to support a person with disability.  It is used in the rehabilitation setting.
• Modified Rankin Scale (MRS) – This measure is used to categorize level of functional independence with reference to pre-stroke activities rather than on observed performance of a specific task.
• Toronto Bedside Swallowing Screening Tool (TOR-BSST©) – A bedside swallowing screening for stroke patients to predict the presence of dysphasia

Quality of Life Scales

• Assessment of Life Habits (LIFE-H) – A tool to assess the quality of social participation of people with disabilities by estimating how a client accomplishes activities of daily living and social roles
• Reintergration to Normal Living Index (RNLI) – This measure was developed to quantitatively assess the degree to which individuals who have experienced traumatic or incapacitating illness achieve reintegration into normal social activities. […..]

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Depression Scales

• Geriatric Depression Scale (GDS) 
• Patient Health Questionnaire-9 (PHQ9)

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Risk Stratification

• ABCD Score
• ABCD2 Score

The ABCD and ABCD2 Scores have been used to predict the risk of stroke during the first seven days after a TIA. […..]