Post-Concussion Symptom Scoring Questionnaire
Please complete this form to help us assess your current symptoms following a concussion. Your responses will assist in your evaluation and care.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you been diagnosed with a concussion in the last 3 months?
*
Yes
No
Please rate the severity of the following symptoms over the past 24 hours.
*
Rows
None (0)
Mild (1)
Moderate (2)
Severe (3)
Headache
1
2
3
4
Nausea or vomiting
5
6
7
8
Dizziness
9
10
11
12
Fatigue or low energy
13
14
15
16
Trouble falling asleep
17
18
19
20
Sensitivity to light
21
22
23
24
Sensitivity to noise
25
26
27
28
Feeling slowed down
29
30
31
32
Difficulty concentrating
33
34
35
36
Difficulty remembering
37
38
39
40
Irritability
41
42
43
44
Sadness
45
46
47
48
Feeling more emotional
49
50
51
52
Nervousness or anxiety
53
54
55
56
Are your symptoms getting better, worse, or staying the same?
*
Better
Worse
About the same
Have you returned to normal activities (school, work, sports)?
*
Yes, fully
Partially
No
Do you have any other symptoms or concerns you would like to mention?
Would you like to be contacted to discuss your symptoms further?
Yes
No
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: