OneHitAway Preliminary Concussion Assessment
Client Name *
Your answer
Date of injury *
Are you filling this out for someone?
Your name and relationship to the client.
Your answer
Email *
Your answer
Best Phone Number to Reach You *
Your answer
Alternate contact *
Please provide someone designated as an alternate contact and provide their phone or email
Your answer
About this questionnaire
In order to better assist you and other athletes, OneHitAway needs your assessment your current condition. We will check back with you in the future to evaluate your progress and determine where additional help might be needed. We want to track your success! Please fill out the questions to the best of your ability, there are no wrong answers. We are part of your team!
Is this your first concussion? If not, how many do you know of?
Please describe your last concussion, including injury area:
Your answer
Was it sports related?
Your answer
If yes, which sport?
Physical Symptoms
Your Physical Symptoms *
Use the 0-5 scale to tell us how you are feeling right now.
This does not apply to me
Infrequent (less than once per week)
2-3 times per week
More than three times per week
Debilitating, cannot function with this condition
Pain at injury site
Other pain (neck, back)
Balance issues, unsteadiness
Blurred or Double Vision
Sensitivity to light
Sensitivity to sound
Additional Physical Symptoms
Is there something bothering you that is not on this list? Please tell us.
Your answer
Changes in Habits and Activities
Please rate the following items
Changes in Health, Habits, and Activities *
Please rate the items on the following list, keeping in mind we are looking for things that have changed since your head injury.
This does not apply to me
This happens infrequently – less than once a week
This happens often, 2-3 three times a week.
This happens more than 3 times a week
This is debilitating and making it difficult to function
I have trouble sleeping
I have trouble staying awake during the day
I have short term memory problems
I have long-term memory problems
I physically have trouble exercizing or staying active
I have changes in smell
I have changes in hearing
I have changes in eyesight
Something not on this list?
Do you have a physical symptom(s) not on this list? Please tell us about it.
Your answer
Changes in Mood, Behavior, Well-Being
Changes in Mood, Behavior, Overall Feeling of Well-Being
Please rate these items to the best of your ability
This does not apply to me
This applies to me occasionally
I often feel like this
I feel like this all the time
This is profoundly affecting my quality of life
I dont feel like myself
I am easily confused
I get angry easily
I feel depressed
I have difficulty concentrating
I have difficulty completing tasks I used to do easily
I feel like I am in a fog
I feel anxious
I have trouble finding the right words
I do not feel like exercizing
Are you experiencing something not on this list? Or would you like to comment more on your answers above?
Please describe your experience and how it is affecting your quality of life.
Your answer
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