Head Assessment Form
Complete this Head Assessment Form to evaluate current symptoms and head-related concerns.
What is the primary reason for this head assessment?
*
Headache
Injury
Dizziness
Other
Where is the discomfort or pain primarily located?
*
Forehead
Back of head
Sides of head
Top of head
Face/temples
Other
How severe is your discomfort or pain right now?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
How long have you been experiencing these symptoms?
*
Less than 1 hour
1-6 hours
6-24 hours
1-3 days
More than 3 days
Do you have any of the following symptoms? (Select all that apply)
*
Nausea or vomiting
Blurred or double vision
Dizziness or loss of balance
Sensitivity to light or sound
Confusion or memory issues
None of the above
Other
Have you experienced any recent head trauma (e.g., bump, fall, hit)?
*
Yes
No
Not sure
Please rate the impact of your symptoms on daily activities.
*
1
2
3
4
5
Please indicate how much you agree with the following statements about your current state.
*
Rows
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I feel alert
1
2
3
4
5
I have good concentration
6
7
8
9
10
I am able to perform usual tasks
11
12
13
14
15
I am able to communicate clearly
16
17
18
19
20
Have you taken any medication or treatment for your symptoms?
*
Yes
No
Please describe any other symptoms or details relevant to your head assessment.
Submit Assessment
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