POST-CONCUSSION SYMPTOM SCALE & FOLLOW-UP EXAM

Name: __________________________ Sport:__________ Injury Date:__________

Todays Date:__________
SYMPTOM SEVERITY
None Moderate Severe
Heada!e " # $ % & ' (
)Pressure *n !ead+ " # $ % & ' (
Ne, pa*n " # $ % & ' (
Nausea or vom*t*n- " # $ % & ' (
.a/ane pro0/ems " # $ % & ' (
D*11*ness " # $ % & ' (
2at*-ue or /o3 ener-y " # $ % & ' (
Trou0/e 4a//*n- as/eep " # $ % & ' (
Sens*t*v*ty to /*-!t " # $ % & ' (
Sens*t*v*ty to no*se " # $ % & ' (
Irr*ta0*/*ty " # $ % & ' (
2ee/*n- s/o3ed do3n " # $ % & ' (
2ee/*n- )*n a 4o-+ " # $ % & ' (
D*44*u/ty onentrat*n- " # $ % & ' (
./urred v*s*on " # $ % & ' (
)Dont 4ee/ r*-!t+ " # $ % & ' (
D*44*u/ty remem0er*n- " # $ % & ' (
5on4us*on " # $ % & ' (
Dro3s*ness " # $ % & ' (
More emot*ona/ " # $ % & ' (
Sadness " # $ % & ' (
Nervous or an6*ous " # $ % & ' (
PHYSI578 E97M:
Pre:e6ert*on Post:e6ert*on
2;2 to 2;N 6 %< E=O= # $ % # $ %
2;2 to 2;N 6 %< E=5= # $ % # $ %
S8. 6 #"ses< E=O= # $ % # $ %
S8. 6 #"ses< E=5= # $ % # $ %
% >s .? ________ Y ; N Y ; N
& >s .? ________ Y ; N Y ; N
' >s .? ________ Y ; N Y ; N
E9ERTION:
_____ Pus!:ups _____ S*t:ups _____ @@s _____ M*ns .*,e _____ M*/e Run _____?ts _____N;5p6