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Post-Concussion Symptom Assessment

This document contains a post-concussion symptom scale and follow-up exam for a patient. It lists 22 common post-concussion symptoms and asks the patient to rate the severity of each symptom. It also includes sections to record pre-and post-exertion test results, including balance, coordination and cognitive tests. The exam is used to monitor the recovery of a patient from a concussion by tracking symptoms and performance on physical and cognitive tests over time.

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48 views1 page

Post-Concussion Symptom Assessment

This document contains a post-concussion symptom scale and follow-up exam for a patient. It lists 22 common post-concussion symptoms and asks the patient to rate the severity of each symptom. It also includes sections to record pre-and post-exertion test results, including balance, coordination and cognitive tests. The exam is used to monitor the recovery of a patient from a concussion by tracking symptoms and performance on physical and cognitive tests over time.

Uploaded by

POOPPPP12345
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

POST-CONCUSSION SYMPTOM SCALE & FOLLOW-UP EXAM

Name: __________________________ Sport:__________ Injury Date:__________


Todays Date:__________
SYMPTOM SEVERITY
None Moderate Severe
Heada!e " # $ % & ' (
)Pressure *n !ead+ " # $ % & ' (
Ne, pa*n " # $ % & ' (
Nausea or vom*t*n- " # $ % & ' (
.a/ane pro0/ems " # $ % & ' (
D*11*ness " # $ % & ' (
2at*-ue or /o3 ener-y " # $ % & ' (
Trou0/e 4a//*n- as/eep " # $ % & ' (
Sens*t*v*ty to /*-!t " # $ % & ' (
Sens*t*v*ty to no*se " # $ % & ' (
Irr*ta0*/*ty " # $ % & ' (
2ee/*n- s/o3ed do3n " # $ % & ' (
2ee/*n- )*n a 4o-+ " # $ % & ' (
D*44*u/ty onentrat*n- " # $ % & ' (
./urred v*s*on " # $ % & ' (
)Dont 4ee/ r*-!t+ " # $ % & ' (
D*44*u/ty remem0er*n- " # $ % & ' (
5on4us*on " # $ % & ' (
Dro3s*ness " # $ % & ' (
More emot*ona/ " # $ % & ' (
Sadness " # $ % & ' (
Nervous or an6*ous " # $ % & ' (
PHYSI578 E97M:
Pre:e6ert*on Post:e6ert*on
2;2 to 2;N 6 %< E=O= # $ % # $ %
2;2 to 2;N 6 %< E=5= # $ % # $ %
S8. 6 #"ses< E=O= # $ % # $ %
S8. 6 #"ses< E=5= # $ % # $ %
% >s .? ________ Y ; N Y ; N
& >s .? ________ Y ; N Y ; N
' >s .? ________ Y ; N Y ; N
E9ERTION:
_____ Pus!:ups _____ S*t:ups _____ @@s _____ M*ns .*,e _____ M*/e Run _____?ts _____N;5p6

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