Post-Injury Test Record rev 01-2020.xlsx

	A	B	C	E	G	H	J	K	L
1	Concussion Post-Injury Test Record
2	Concussion Post-Injury Test Record
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4	Westwood High School 12400 Mellow Meadow Dr. Austin, TX 78613 (512) 464-4053 office (512) 464-4030 fax		John Horsley LAT, ATC Mackenzie Poole LAT, ATC		Athlete Name: __________________________________ Student ID # ______________ School: ______________ DOI: _______________ Assesment Date: ____________ Grade: _________ DOB: ______________ Age: ______ Height: ______ Weight:_____
5			John Horsley LAT, ATC Mackenzie Poole LAT, ATC
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7	Post Concussion Symptom Scale (PCSS) CHECK LIST NOTE: Grading of symptom severity on a scale 0-6 (None to Severe)			KING-DEVICK TEST			Vestibular/Ocular Motor Screen VOMS
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9	Physical Findings	Headache		Baseline	Post-Injury		TEST (Symptoms 0-10)	HA / Dizzy/	Naus / Fog
10		Pressure in Head		Date:	Date:		Baseline	/	/
11		Neck Pain		TOTAL TIME	TIME/ ERRORS		Smooth Pursuit x2	/	/
12		Nausea/Vomitting		TOTAL TIME	TIME/ ERRORS		Vertical Saccade x10	/	/
13		Balance Problems					Horiz Saccade x10	/	/
14		Dizziness		COORDINATION EXAM (Finger to Nose)			Convergence	Near Point (<5cm)
15		Visual Problems		COORDINATION EXAM (Finger to Nose)				Measure 1: _____
16		Fatigue/Low Energy		Completes Trial within 4 sec		Yes/No		Measure 2: _____
17		Sensitivity to Light		Completes Trial within 4 sec		Yes/No		Measure 3: _____
18		Sensitivity to Noise					Convergence Sx	/	/
19		Numbness/Tingling		Balance Testing (mBESS) 20sec				VOR (180bpm)
20				Balance Testing (mBESS) 20sec			VOR - Horizontal x10	/	/
21	Cognitive Findings	Feeling Slowed Down		Foot: L / R	Surface:		VOR - Vertical x10	/	/
22		Feeling Mentally "Foggy"		Double Leg Stance		/10		VMS (50bpm)
23		“Don’t Feel Right”		Single Leg (Non-Dom)		/10	VMS Test x5	/	/
24		Difficulty Concentrating		Tandem (Non-Dom Back)		/10
25		Difficulty Remembering					Immediate/Delayed Recall
26				AMNESIA		Yes/No	Immediate/Delayed Recall
27	Emotional Findings	Irritability		AMNESIA		Yes/No
28		Sadness		Anterograde (Duration)			Set 1
29		More Emotional		Retrograde (Duration)			Finger - Penny - Blanket - Lemon - Sandwich		/5
30		Nervous/Anxious							/5
31				PAST HISTORY Pre-Existing Conditions					/5
32	Sleep Findings	Drowsiness		PAST HISTORY Pre-Existing Conditions			Set 2
33		Sleeping Less		Pv Concussions #: _______		Yes/No	Candle - Paper - Sugar - Sandwich - Wagon		/5
34		Sleeping More		Dates:					/5
35		Trouble Falling Asleep		Hx of Car/Motion Sickness		Yes/No			/5
36				Learning Disabilities		Yes/No	Set 3
37	Total Number Symptoms (24 Max) Severity (Sum of Scores) (144 Max)			Depression/Anxiety		Yes/No	Baby - Monkey - Perfume - Sunset - Iron		/5
38				History of Migraines		Yes/No			/5
39				Family Hx of above		Yes/No			/5
40							Delayed Recall - 5 minute delay
41		Repeat Months in Reverse Order					Set #:		/5
42		Dec-Nov-Oct-Sep-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan			Yes / No		Set #:		/5
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44	Comments:
45	______________________________________________________________________________________________________________________________
46	______________________________________________________________________________________________________________________________
47	______________________________________________________________________________________________________________________________
48	______________________________________________________________________________________________________________________________
49	______________________________________________________________________________________________________________________________
50	______________________________________________________________________________________________________________________________
51	Description of Tests Performed
52	Description of Tests Performed
53	Symptoms Checklist		The Symptom Checklist is based on a 0-6 scale with 6 being the most severe and 1 being the least. If the athlete has no symptoms then they rate it a 0. Max number of symptoms is 24/24 symptoms and the max severity score is 144/144
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55	King-Devick Test		The King-Devick is a visual tracking timed test. It is a three page test with each page gradually increasing in difficulty. The athlete is instructed to read out loud each page (a series of numbers) from left to right and proceed to the next line until completed. The athlete is timed for each page and then a total time is produced. The baseline is compared to the post-injury test. If the post-injury test is slower then that may indicate a possible concussion.
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57	Balance Bess Test		Have the athlete remove their shoes if possible. With their eyes closed, have them hold each pose for 20 seconds. Mark each error in balance as 1. 10 Errors are max. If they can not do any with their eyes closed, try with eyes open and note the change.
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59	Coordination Exam		The athlete is instructed to touch the tip of their nose with the tip of the finger five times from an extended arm position as fast as they can while staring at a fixed spot.
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61	Eye Tracking Vestibular/Ocular Motor Screening VOMS		VOMS is a screening tool used to assess vestibular-ocular function and potential for protracted recovery. Smooth Pursuits (H test) - 3 Ft. away from athlete have athlete track 1.5 ft left to right and up and down x2. Horiz & Vert Saccades - 3 Ft. away with hands 1.5 ft apart & track 1x10. Near Point Convergence - Stick with target track from arm length toward nose x3, when vision doubles measure distance. Any <5cm is dysfunction. VOR Horiz & Vert - Arm length away target and move head 20° right to left and up & down x10 at 180 bpm. Visual Motion Sensitivity VMS - Fixed head & target move body w/ busy background 80° right to left x5 @ 50 bpm.
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63	Immediate and Delayed Recall		Immediate Recall: Choose one of the sets of words the patient is not familiar with. Repeat it to them slowly and have them repeat it back immedialty in any order. You will do this 3 times. Delayed Recall: Approximately 5 minutes after you have done the Immediate Recall, ask them to tell you the 5 words from before in any order they can remember them.
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65	Months of the Year in Reverse Order		Have the patient repeat the months of the years in reverse order to evaluate recall and processesing. This will be either a yes or a no for completion correctly.
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67	CLINICAL TRAJECTORIES - Based on PCSS & Screening Tests (VOMS, KD, DVA, Coordination Exam & Cervicogenic Screen)
68		Cervical Trajectory	PCSS: HA, Neck Pain, Numbness, Tingling / Test: + Cervicogenic Screen
69		Ocular Motor	PCSS: Difficulty Concentration, Visual Problems, Dizziness, Photophobia / Test: +KD, +VOR & +DVA
70		Vestibular	PCSS: Dizziness, Nausea, Vomiting, Balance, Noise Sensitivity / Test: +VOR & +VMS
71		Cognitive	PCSS: HA, Diffulty Concentrating & Remembering, Low Energy, Fogginess, Drowsy / Test: +KD & - VOMS
72		Anxiety	PCSS: More Emotional, Sadness, Irritability, Nervousness / Test: - KD & - VOMS
73		Migraine	PCSS: HA, Photophobia, Noise Sensitivity, Photophobia, Nausea, Vomiting, Balance, Numbness, Dizzy / Test: - VOMS, - KD
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