Post-Concussion Symptom Evaluation

Full Name *

Date *

(0) None, (1) Mild, (2) Mild, (3) Moderate, (4) Moderate (5) Severe, (6) Severe

1. Headache *

2. "Pressure" in head *

3. Neck pain *

4. Nausea or vomiting *

5. Dizziness *

6. Blurred vision *

7. Balance problems *

8. Sensitivity to light *

9. Sensitivity to noise *

10. Feeling slowed down *

11. Feeling like "in a fog" *

12. "Don't feel right" *

13. Difficulty concentrating *

14. Difficulty remembering *

15. Fatigue or low energy *

16. Confusion *

17. Drowsiness *

18. More emotional *

19. Irritability *

20. Sadness *

21. Nervous or Anxious *

22. Trouble falling asleep (if applicable) *

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