POST-CONCUSSION SYMPTOM SCALE & FOLLOW-UP EXAM

Name: __________________________ Sport:__________ Injury Date:__________

Todays Date:__________
SYMPTOM

SEVERITY
None

Headache
Pressure in head
Neck pain
Nausea or vomiting
Balance problems
Dizziness
Fatigue or low energy
Trouble falling asleep
Sensitivity to light
Sensitivity to noise
Irritability
Feeling slowed down
Feeling in a fog
Difficulty concentrating
Blurred vision
Dont feel right
Difficulty remembering
Confusion
Drowsiness
More emotional
Sadness
Nervous or anxious

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Moderate
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3

Severe
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4

5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5

6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6

PHYSICAL EXAM:
Pre-exertion
F/F to F/N x 3; E.O.
F/F to F/N x 3; E.C.
SLB x 10secs; E.O.
SLB x 10secs; E.C.
3 #s BW ________
4 #s BW ________
5 #s BW ________

1
1
1
1

2
2
2
2
Y / N
Y / N
Y / N

Post-exertion
3
3
3
3

1
1
1
1

2
2
2
2
Y / N
Y / N
Y / N

3
3
3
3

EXERTION:
_____ Push-ups _____ Sit-ups _____ JJs _____ Mins Bike _____ Mile Run _____Wts _____N/Cpx