ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
Name: Date of Concussion:Method of Injury:
2
ID#
3
4
5
Graded Sympton Checklist
6
7
SymptomTime of InjuryDateDateDateDate
8
9
Blurred vision
10
Seeing stars
11
Sensitivity to light
12
Vacant stare/glassy eyed
13
Nystagmus
14
Dizziness
15
Nausea
16
Vomiting
17
Headache
18
Irritability
19
Nervousness
20
Ringing in ears
21
Sensitivity to noise
22
Drowsiness
23
Excessive sleep
24
Fatigue
25
Sleep disturbance
26
Easily distracted
27
Feel "in a fog"
28
Feel "slowed down"
29
Inappropriate emotions
30
Loss of orientation
31
Personality change
32
Sadness
33
Loss of consciousness
34
Memory problems
35
Poor concentration
36
Poor balance/coordination
37
38
Scoring: 0-6, 0=not present
39
1= mild; 6= most severe
40
41
BESS scoring:
42
43
Parents informed/handouts
44
School nurse informed
45
ImPACT test dates/ pass
46
Begin RTP protocol
47
Dr. release to RTP
48
UIL form completed
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100