Concussion Symptom Score Sheet
Honestly rate each of the symptoms you are currently experiencing.
Family name *
Your answer
First name *
Your answer
Nausea or vomiting *
None
Severe
Headache *
None
Severe
Dizziness or light headed *
None
Severe
Head Pressure *
None
Severe
Vision problems or blurriness *
None
Severe
Difficulty balancing or coordination *
None
Severe
Feeling slowed down with thoughts or feeling of "in a fog" *
None
Severe
Light or noise sensitivity *
None
Severe
Difficulty concentrating *
None
Severe
Difficulty remembering *
None
Severe
Difficulty falling asleep *
None
Severe
Fatigue, drowsy, or low energy *
None
Severe
Confusion *
None
Severe
Sleeping more than usual *
None
Severe
Nervous, anxiousness, irritable *
None
Severe
Emotional or sad *
None
Severe
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