{
  "template": {
    "code": "nihss",
    "name": "NIH Stroke Scale",
    "category": "disease",
    "version": 1,
    "is_current": true,
    "is_active": true,
    "scoring_strategy": "sum_items",
    "description": "National Institutes of Health Stroke Scale (NIHSS). Total 0–42. Required on stroke pathway activation.",
    "meta": {
      "capture_roles": ["doctor"],
      "specialty": "neurology",
      "estimated_minutes": 10,
      "pathway_codes": ["stroke"],
      "max_total": 42,
      "attribution": "NIH Stroke Scale (NIHSS) — public-domain clinical instrument originating from NINDS/NIH. Confirm local training and documentation requirements for clinical use."
    }
  },
  "questions": [
    {
      "code": "1a_loc",
      "section": "1. Level of consciousness",
      "label": "1a. Level of consciousness",
      "help_text": "Alertness.",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 10,
      "score_key": "loc",
      "options": {
        "min": 0,
        "max": 3,
        "choices": [
          { "code": "0", "label": "Alert; keenly responsive", "score": 0 },
          { "code": "1", "label": "Not alert; arousable by minor stimulation", "score": 1 },
          { "code": "2", "label": "Not alert; requires repeated stimulation / obtunded", "score": 2 },
          { "code": "3", "label": "Responds only with reflex motor or autonomic effects / totally unresponsive", "score": 3 }
        ]
      }
    },
    {
      "code": "1b_loc_questions",
      "section": "1. Level of consciousness",
      "label": "1b. LOC questions",
      "help_text": "Month and age. Score only initial answer.",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 20,
      "score_key": "loc",
      "options": {
        "min": 0,
        "max": 2,
        "choices": [
          { "code": "0", "label": "Answers both questions correctly", "score": 0 },
          { "code": "1", "label": "Answers one question correctly", "score": 1 },
          { "code": "2", "label": "Answers neither question correctly", "score": 2 }
        ]
      }
    },
    {
      "code": "1c_loc_commands",
      "section": "1. Level of consciousness",
      "label": "1c. LOC commands",
      "help_text": "Open and close eyes; grip and release non-paretic hand.",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 30,
      "score_key": "loc",
      "options": {
        "min": 0,
        "max": 2,
        "choices": [
          { "code": "0", "label": "Performs both tasks correctly", "score": 0 },
          { "code": "1", "label": "Performs one task correctly", "score": 1 },
          { "code": "2", "label": "Performs neither task correctly", "score": 2 }
        ]
      }
    },
    {
      "code": "2_gaze",
      "section": "2. Best gaze",
      "label": "2. Best gaze",
      "help_text": "Horizontal eye movements only.",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 40,
      "score_key": "gaze",
      "options": {
        "min": 0,
        "max": 2,
        "choices": [
          { "code": "0", "label": "Normal", "score": 0 },
          { "code": "1", "label": "Partial gaze palsy", "score": 1 },
          { "code": "2", "label": "Forced deviation, or total gaze paresis not overcome by oculocephalic maneuver", "score": 2 }
        ]
      }
    },
    {
      "code": "3_visual",
      "section": "3. Visual",
      "label": "3. Visual fields",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 50,
      "score_key": "visual",
      "options": {
        "min": 0,
        "max": 3,
        "choices": [
          { "code": "0", "label": "No visual loss", "score": 0 },
          { "code": "1", "label": "Partial hemianopia", "score": 1 },
          { "code": "2", "label": "Complete hemianopia", "score": 2 },
          { "code": "3", "label": "Bilateral hemianopia (blind including cortical blindness)", "score": 3 }
        ]
      }
    },
    {
      "code": "4_facial",
      "section": "4. Facial palsy",
      "label": "4. Facial palsy",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 60,
      "score_key": "facial",
      "options": {
        "min": 0,
        "max": 3,
        "choices": [
          { "code": "0", "label": "Normal symmetrical movements", "score": 0 },
          { "code": "1", "label": "Minor paralysis (flattened nasolabial fold, asymmetry on smiling)", "score": 1 },
          { "code": "2", "label": "Partial paralysis (total or near-total paralysis of lower face)", "score": 2 },
          { "code": "3", "label": "Complete paralysis of one or both sides (upper and lower face)", "score": 3 }
        ]
      }
    },
    {
      "code": "5a_motor_arm_left",
      "section": "5. Motor arm",
      "label": "5a. Motor arm — left",
      "help_text": "Extend arms 90° (sitting) or 45° (supine) for 10 seconds.",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 70,
      "score_key": "motor_arm",
      "options": {
        "min": 0,
        "max": 4,
        "choices": [
          { "code": "0", "label": "No drift; limb holds 90° (or 45°) for full 10 seconds", "score": 0 },
          { "code": "1", "label": "Drift; limb holds but drifts down before full 10 seconds", "score": 1 },
          { "code": "2", "label": "Some effort against gravity", "score": 2 },
          { "code": "3", "label": "No effort against gravity; limb falls", "score": 3 },
          { "code": "4", "label": "No movement", "score": 4 },
          { "code": "UN", "label": "Amputation or joint fusion (score as 0 for total; document)", "score": 0 }
        ]
      }
    },
    {
      "code": "5b_motor_arm_right",
      "section": "5. Motor arm",
      "label": "5b. Motor arm — right",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 80,
      "score_key": "motor_arm",
      "options": {
        "min": 0,
        "max": 4,
        "choices": [
          { "code": "0", "label": "No drift; limb holds 90° (or 45°) for full 10 seconds", "score": 0 },
          { "code": "1", "label": "Drift; limb holds but drifts down before full 10 seconds", "score": 1 },
          { "code": "2", "label": "Some effort against gravity", "score": 2 },
          { "code": "3", "label": "No effort against gravity; limb falls", "score": 3 },
          { "code": "4", "label": "No movement", "score": 4 },
          { "code": "UN", "label": "Amputation or joint fusion (score as 0 for total; document)", "score": 0 }
        ]
      }
    },
    {
      "code": "6a_motor_leg_left",
      "section": "6. Motor leg",
      "label": "6a. Motor leg — left",
      "help_text": "Hold leg at 30° for 5 seconds (always tested supine).",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 90,
      "score_key": "motor_leg",
      "options": {
        "min": 0,
        "max": 4,
        "choices": [
          { "code": "0", "label": "No drift; leg holds 30° for full 5 seconds", "score": 0 },
          { "code": "1", "label": "Drift; leg falls by the end of 5-second period but does not hit bed", "score": 1 },
          { "code": "2", "label": "Some effort against gravity; leg falls to bed by 5 seconds", "score": 2 },
          { "code": "3", "label": "No effort against gravity; leg falls to bed immediately", "score": 3 },
          { "code": "4", "label": "No movement", "score": 4 },
          { "code": "UN", "label": "Amputation or joint fusion (score as 0 for total; document)", "score": 0 }
        ]
      }
    },
    {
      "code": "6b_motor_leg_right",
      "section": "6. Motor leg",
      "label": "6b. Motor leg — right",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 100,
      "score_key": "motor_leg",
      "options": {
        "min": 0,
        "max": 4,
        "choices": [
          { "code": "0", "label": "No drift; leg holds 30° for full 5 seconds", "score": 0 },
          { "code": "1", "label": "Drift; leg falls by the end of 5-second period but does not hit bed", "score": 1 },
          { "code": "2", "label": "Some effort against gravity; leg falls to bed by 5 seconds", "score": 2 },
          { "code": "3", "label": "No effort against gravity; leg falls to bed immediately", "score": 3 },
          { "code": "4", "label": "No movement", "score": 4 },
          { "code": "UN", "label": "Amputation or joint fusion (score as 0 for total; document)", "score": 0 }
        ]
      }
    },
    {
      "code": "7_ataxia",
      "section": "7. Limb ataxia",
      "label": "7. Limb ataxia",
      "help_text": "Finger-nose-finger and heel-shin tests on both sides.",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 110,
      "score_key": "ataxia",
      "options": {
        "min": 0,
        "max": 2,
        "choices": [
          { "code": "0", "label": "Absent", "score": 0 },
          { "code": "1", "label": "Present in one limb", "score": 1 },
          { "code": "2", "label": "Present in two limbs", "score": 2 },
          { "code": "UN", "label": "Amputation or joint fusion (score as 0; document)", "score": 0 }
        ]
      }
    },
    {
      "code": "8_sensory",
      "section": "8. Sensory",
      "label": "8. Sensory",
      "help_text": "Sensation or grimace to pinprick when consciousness decreased.",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 120,
      "score_key": "sensory",
      "options": {
        "min": 0,
        "max": 2,
        "choices": [
          { "code": "0", "label": "Normal; no sensory loss", "score": 0 },
          { "code": "1", "label": "Mild-to-moderate sensory loss", "score": 1 },
          { "code": "2", "label": "Severe to total sensory loss", "score": 2 }
        ]
      }
    },
    {
      "code": "9_language",
      "section": "9. Best language",
      "label": "9. Best language",
      "help_text": "Describe picture, name items, read sentences.",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 130,
      "score_key": "language",
      "options": {
        "min": 0,
        "max": 3,
        "choices": [
          { "code": "0", "label": "No aphasia; normal", "score": 0 },
          { "code": "1", "label": "Mild-to-moderate aphasia", "score": 1 },
          { "code": "2", "label": "Severe aphasia", "score": 2 },
          { "code": "3", "label": "Mute, global aphasia; no usable speech or auditory comprehension", "score": 3 }
        ]
      }
    },
    {
      "code": "10_dysarthria",
      "section": "10. Dysarthria",
      "label": "10. Dysarthria",
      "help_text": "Read or repeat words from list.",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 140,
      "score_key": "dysarthria",
      "options": {
        "min": 0,
        "max": 2,
        "choices": [
          { "code": "0", "label": "Normal", "score": 0 },
          { "code": "1", "label": "Mild-to-moderate dysarthria", "score": 1 },
          { "code": "2", "label": "Severe dysarthria; unintelligible or mute/anarthric", "score": 2 },
          { "code": "UN", "label": "Intubated or other physical barrier (score as 0; document)", "score": 0 }
        ]
      }
    },
    {
      "code": "11_extinction",
      "section": "11. Extinction and inattention",
      "label": "11. Extinction and inattention (formerly neglect)",
      "answer_type": "score_item",
      "is_required": true,
      "sort_order": 150,
      "score_key": "extinction",
      "options": {
        "min": 0,
        "max": 2,
        "choices": [
          { "code": "0", "label": "No abnormality", "score": 0 },
          { "code": "1", "label": "Visual, tactile, auditory, spatial, or personal inattention; or extinction to bilateral simultaneous stimulation in one sensory modality", "score": 1 },
          { "code": "2", "label": "Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space", "score": 2 }
        ]
      }
    }
  ]
}
