Post-Concussion Test

  • 1
  • 2
  • 3
  • 4
  • 5


Physical Symptoms

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Headache

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Nausea

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Vomiting

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Dizziness

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Blurry or double vision

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Sensitivity to light

Sensitivity to noise

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Balance problems

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Pain other than headache

Thinking/ Cognitive & Sleep Issues

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Feeling slowed down

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Difficulty concentrating

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Difficulty remembering

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Trouble falling asleep

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Fatigue or low energy

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Drowsiness

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Feeling “in a fog”

Emotional Symptoms

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Feeling more emotional

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Irritability

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Sadness

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Nervousness

Rivermead Post Concussion Symptoms

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from

Headaches

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Feelings of Dizziness

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Nausea and/or vomiting

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Noise Sensitivity, easily upset by loud noise

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Sleep Disturbance

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Fatigue, tired easily

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Being Irritable, easily angered

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Feeling depressed or tearful

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Feeling frustrated or impatient

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Forgetfulness, poor memory

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Poor Concentration

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Taking longer to think

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Blurred vision

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Light sensitivity, easily upset by bright light

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Double vision

Compared with before the accident, do you now (i.e, over the last 24 hours) suffer from:

Restlessness