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Amyotrophic lateral sclerosis (ALS): Suspect-and-test checklist for clinicians

A one-page worksheet that turns the full Amyotrophic lateral sclerosis (ALS) diagnosis guide into something you can use at the point of care: what to look for, what to order, which results should not end the workup, and who else to test or refer.

Who it is forClinicians and care teams who may see Amyotrophic lateral sclerosis (ALS) before it is diagnosed, including primary care, the specialists named in the guide, and referral or genetics coordinators.
When to use itWhen Amyotrophic lateral sclerosis (ALS) is on the differential, when a patient has several red flags, or when you are preparing a referral or a second opinion.

How to use it, section by section

  1. Red flags present: Tick each finding the patient has. They are grouped by body system so you can scan quickly.
  2. Already labeled as: Tick earlier diagnoses on the chart that the sources say are often given first.
  3. Family to test: Note relatives who may need testing, and record when symptoms began and which specialists have already been seen.
  4. Testing, in order: Tick each test as you order it and write the result on its line. The order follows the published sources.
  5. Results that do not rule it out: A reminder of findings that can look reassuring but do not exclude Amyotrophic lateral sclerosis (ALS).
  6. Specialists: Tick the referral, then write who it went to and any notes.
Two ways to fill it inPrint it blank and write on it, or tick boxes and type on this screen first, then print or save as a PDF. Keep it with the chart or send it with the referral.
PrivacyNothing you type is sent or saved. It stays in this browser tab and disappears when you close it. Use patient initials, not full identifiers.

What it is not: Not a diagnostic score, a protocol or coding advice. It summarizes published sources, and clinical judgment and the treating clinician govern. Every point is sourced in the full Amyotrophic lateral sclerosis (ALS) guide.

One Letter page. Use your browser's print or save as PDF.Full guide with sources
Suspect-and-test checklist
Amyotrophic lateral sclerosis (ALS)

Progressive, purely motor weakness with upper and lower motor neuron signs. A clinical diagnosis: EMG supports it, and imaging and blood tests look for mimics.

ICD-10-CMG12.21Trial Friend for Clinicians

1Red flags present

Any setting

Limb onset (orthopedics, hand, spine)

Bulbar onset (ENT, speech, stroke clinic)

Respiratory onset (pulmonology, emergency)

Family history

2Already labeled as

3Family to test

4Testing, in the order the sources describe

  1. History and neurological examinationThe diagnosis remains fundamentally clinical, per the UK MND Clinical Studies Group.
    Result
  2. Gold Coast criteriaProgressive motor impairment; UMN plus LMN signs in 1 region or LMN signs in 2; other diseases excluded.
    Result
  3. Needle EMGShows occult LMN involvement. Far from 100% sensitive, especially in bulbar-onset, UMN-predominant disease.
    Result
  4. Nerve conduction studies, anti-GM1 antibodiesConduction block points to multifocal motor neuropathy. Anti-GM1 is only 50% sensitive.
    Result
  5. MRI: cervical spine, brain or lumbar spineChosen by the clinical picture. Incidental spondylosis is common in people with ALS.
    Result
  6. Creatine kinase; thyroid function, electrolytes; B12, copperCK above 1000IU/L suggests another diagnosis. About 10% of thyrotoxic patients fasciculate.
    Result
  7. AR CAG repeat test; muscle biopsyKennedy disease in men with slow LMN syndrome. Inclusion body myositis with finger flexor weakness.
    Result
  8. Genetic testing with counselingOffer to all with ALS, per a 2023 US guideline: C9orf72 assay plus SOD1, FUS and TARDBP sequencing.
    Result
  9. SOD1 resultQalsody (tofersen) label: adults with ALS who have a SOD1 mutation.
    Result

5Results the sources say do not rule it out

  • A normal EMG in bulbar-onset disease. Tongue and limb EMG findings are often lacking.
  • Spondylosis with root or cord impingement on MRI. ALS can still be the cause of weakness.
  • No upper motor neuron signs. Gold Coast accepts LMN dysfunction in 2 body regions.
  • A negative gene panel. Testing finds no cause in a significant proportion of familial cases.
  • A working diagnosis of ALS with atypical features or no progression. In an Irish register, 7.3% were rediagnosed with a mimic.

6Specialists the sources name

Diagnosis code: G12.21 Amyotrophic lateral sclerosisCodes patients often carry before diagnosis are listed in the online guide.
Full guide and sourcesEvery point here is sourced in the online guide, which also has a patient note to print.
Trial Friend, trialfriend.com/for-clinicians. Key sources: Gold Coast criteria proposal (2020); UK MND Clinical Studies Group on the Gold Coast criteria (2022); Awaji consensus (2007); Shrestha 2026 meta-analysis; Shen 2021 Beijing cohort; Hannaford 2021 Sydney cohort; all 39 with links in the online guide. Checked November 12, 2026. A reference checklist for licensed clinicians that summarizes published sources. It is not a diagnostic tool, a score or a protocol, and it does not replace clinical judgment, local practice or the prescribing information. Not coding advice. Trial Friend never receives anything written or typed on this sheet.