Acute Concussion Questionnaire

Acute Concussion Questionnaire
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Date/Time of Injury*
Injury Description
Symptom Check List

Physical

	Yes	No
Headache
Nausea
Vomiting
Balance Problems
Dizziness
Visual Problems
Fatigue
Sensitivity to Light
Sensitivity to Noise
Numbness/Tingling

Cognitive

	Yes	No
Feeling Mentally Foggy
Feeling Slowed Down
Difficulty Concentrating
Difficulty Remembering

Emotional

	Yes	No
Irritability
Sadness
More Emotional
Nervousness

Sleep

	Yes	No
Drowziness
Sleeping Less than Usual
Sleeping More than Usual
Trouble Falling Asleep

RED FLAGS for acute emergency management: Refer to the emergency department with sudden onset if any of the following:

*Headaches that worsen *Looks very drowsy/can't be awakened *Weakness/Numbness in arms/legs

*Seizures *Repeated vomiting *Increasing confusion or irritability

*Focal neurologic signs *Slurred speech *Can't recognize people or places

*Neck pain *Unusal behavioral changes *Change in state of consciousness
Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty: