Concussion Symptoms Survey
Please complete this survey to help assess possible symptoms following a head injury. This information will help determine if further medical evaluation is needed.
Full Name (optional)
First Name
Last Name
Age
*
Date and time of injury (if known)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
How did the injury occur?
Please select any symptoms you are currently experiencing:
*
Headache
Nausea or vomiting
Dizziness or balance problems
Sensitivity to light
Sensitivity to noise
Blurred or double vision
Confusion or difficulty concentrating
Memory problems
Feeling sluggish or foggy
Sleep disturbances
Irritability or mood changes
Loss of consciousness (even briefly)
Other
When did these symptoms begin?
Have your symptoms changed since the injury?
Improved
Worsened
Stayed the same
Have you sought medical attention for this injury?
*
Yes
No
If yes, please provide details (e.g., when and where you were seen, any diagnosis or recommendations).
Is there anything else you would like to share about your symptoms or injury?
Submit Survey
Should be Empty: