Patient Intake - Concussion Supplement - Vasta Performance Training and Physical Therapy

First Name(Required)

Last Name(Required)

Email

Date

Date of Birth

Please complete the Concussion Symptom Scoring Sheet for your symptoms today. You should score yourself on the following symptoms, based on how you feel now.

Headache(Required)

Please enter a number from 0 to 6.

“Pressure in Head”(Required)

Please enter a number from 0 to 6.

Neck Pain(Required)

Please enter a number from 0 to 6.

Nausea or Vomiting(Required)

Please enter a number from 0 to 6.

Dizziness(Required)

Please enter a number from 0 to 6.

Blurred Vision(Required)

Please enter a number from 0 to 6.

Balance Problems(Required)

Please enter a number from 0 to 6.

Sensitivity to Light(Required)

Please enter a number from 0 to 6.

Sensitivity to Noise(Required)

Please enter a number from 0 to 6.

Feeling Slowed Down(Required)

Please enter a number from 0 to 6.

Feeling like “in a fog”(Required)

Please enter a number from 0 to 6.

“Don’t Feel Right”(Required)

Please enter a number from 0 to 6.

Difficulty Concentrating(Required)

Please enter a number from 0 to 6.

Difficulty Remembering(Required)

Please enter a number from 0 to 6.

Fatigue or Low Energy(Required)

Please enter a number from 0 to 6.

Confusion(Required)

Please enter a number from 0 to 6.

Drowsiness(Required)

Please enter a number from 0 to 6.

Trouble Falling Asleep(Required)

Please enter a number from 0 to 6.

More Emotional(Required)

Please enter a number from 0 to 6.

Irritability(Required)

Please enter a number from 0 to 6.

Sadness(Required)

Please enter a number from 0 to 6.

Nervous or Anxious(Required)

Please enter a number from 0 to 6.

Total Symptom Severity Score (Max 132)

*Please list any Symptoms that were present immediately after the initial concussive event

Please complete the Dizziness Handicap Inventory

If Yes, please describe

If Yes, for how long?

Do you have a Prior History of (Previous to this injury):

If you answered Yes to previous concussion, please explain (Number, Dates, Mechanisms, Recovery)

Please provide us with a description to the support system you have in place at home

Please provide us with a description to the support system you have in place at school

Patient Signature

Date

Parent/Guardian Signature: (If Applicable)

Date