Concussion Physical Exam Form
Document and assess patients following a suspected concussion. Please complete all relevant sections carefully.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date and Time of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mechanism of Injury (How did the injury occur?)
*
Initial Symptoms After Injury (select all that apply)
*
Headache
Nausea/Vomiting
Dizziness
Confusion
Loss of Consciousness
Blurred Vision
Balance Problems
Other
Current Symptoms Checklist
*
Rows
Not Present
Mild
Moderate
Severe
Headache
1
2
3
4
Nausea
5
6
7
8
Dizziness
9
10
11
12
Sensitivity to Light
13
14
15
16
Sensitivity to Noise
17
18
19
20
Feeling Slowed Down
21
22
23
24
Difficulty Concentrating
25
26
27
28
Memory Problems
29
30
31
32
Fatigue
33
34
35
36
Cognitive Assessment (select the patient's response)
*
Oriented (knows person, place, time)
Disoriented
Confused
Other
Balance Test Result
*
Normal
Impaired
Not Performed
Coordination Test Result (e.g., finger-to-nose, heel-to-shin)
*
Normal
Impaired
Not Performed
Examiner's Notes and Recommendations
Examiner Signature
*
Submit Exam
Submit Exam
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