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Post -concussion checklist
*
Indicates required field
Name
*
First
Last
Please rate the following symptoms from 0-6. "0" being NONE and "6" being SEVERE
Physical Symptoms
Headache
*
0
1
2
3
4
5
6
Physical Fatigue
*
0
1
2
3
4
5
6
Nausea
*
0
1
2
3
4
5
6
Visual Problems
*
0
1
2
3
4
5
6
Vomiting
*
0
1
2
3
4
5
6
Sensitivity to Light
*
0
1
2
3
4
5
6
Balance Problems
*
0
1
2
3
4
5
6
Sensitivity to Noise
*
0
1
2
3
4
5
6
Dizziness
*
0
1
2
3
4
5
6
Cognitive Symptoms
Feeling mentally slowed down
*
0
1
2
3
4
5
6
Feeling in a fog
*
0
1
2
3
4
5
6
Difficulty Concentrating
*
0
1
2
3
4
5
6
Difficulty Remembering
*
0
1
2
3
4
5
6
Sleep Irregularities
Drowsy/ Tired
*
0
1
2
3
4
5
6
Trouble Falling Asleep
*
0
1
2
3
4
5
6
Sleeping More than Usual
*
0
1
2
3
4
5
6
Sleeping Less than Usual
*
0
1
2
3
4
5
6
Emotional Regulation
Irritability
*
0
1
2
3
4
5
6
Nervous/ Anxious
*
0
1
2
3
4
5
6
Easily Emotional
*
0
1
2
3
4
5
6
Sadness
*
0
1
2
3
4
5
6
Activity Level
- Please rate your activity level 0-6 the past 24 hours. "0" being low and "6" being high
Physical Activity Level
*
0
1
2
3
4
5
6
Cognitive/ Thinking Activity Level
*
0
1
2
3
4
5
6
Provide any additional comments about your activity level (optional)
*
Submit
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