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Patient Intake – Concussion Supplement
First Name
(Required)
Last Name
(Required)
Email
Date
MM slash DD slash YYYY
Date of Birth
MM slash DD slash YYYY
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)
Do the symptoms get worse with activity?
Yes
No
Do the symptoms get worse with mental activity?
Yes
No
*Please list any Symptoms that were present immediately after the initial concussive event
Please complete the Dizziness Handicap Inventory
Do you remember the Injury?
Yes
No
If Yes, please describe
Did you experience any loss of consciousness?
Yes
No
If Yes, for how long?
Did you experience memory loss for the time imm BEFORE the injury?
Yes
No
If Yes, for how long?
Did you experience memory loss for the time imm AFTER the injury?
Yes
No
If Yes, for how long?
Have you experienced any hearing changes or ringing in your ear?
Yes
No
If Yes, for how long?
Do you wear glasses and/or corrective lenses?
Yes
No
If Yes, for how long?
Do you have a Prior History of (Previous to this injury):
Headache
Yes
No
Migraine
Yes
No
Family History of Migraine
Yes
No
Dizziness
Yes
No
Learning Disability
Yes
No
Dx of ADHD
Yes
No
Anxiety
Yes
No
Depression
Yes
No
Previous Concussion
Yes
No
Sleep Disorder
Yes
No
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
MM slash DD slash YYYY
Parent/Guardian Signature: (If Applicable)
Date
MM slash DD slash YYYY
Δ
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