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C Post Concussion Checklist

This document is a post-concussion symptom checklist. It lists common physical, cognitive, sleep, and emotional symptoms and asks the person to rate on a scale of 0 to 6 how much each symptom has bothered them over the past 2 days. It also asks if symptoms worsen with physical or cognitive exertion. Finally, it asks the person to rate how different they are acting compared to usual and to indicate their level of activity over the past 2 days compared to normal. The checklist is used to monitor post-concussion symptoms and recovery.

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alston96
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
2K views

C Post Concussion Checklist

This document is a post-concussion symptom checklist. It lists common physical, cognitive, sleep, and emotional symptoms and asks the person to rate on a scale of 0 to 6 how much each symptom has bothered them over the past 2 days. It also asks if symptoms worsen with physical or cognitive exertion. Finally, it asks the person to rate how different they are acting compared to usual and to indicate their level of activity over the past 2 days compared to normal. The checklist is used to monitor post-concussion symptoms and recovery.

Uploaded by

alston96
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Post-Concussion Symptom CHECKLIST

Name: ___________________________ Date: ____/____/______

Instructions: For each item please indicate how much the symptom has bothered you over the past 2 days

Symptoms   none   mild   moderate   severe  


Headache   0   1   2   3   4   5   6  
Nausea   0   1   2   3   4   5   6  
Vomiting   0   1   2   3   4   5   6  
Balance  Problem   0   1   2   3   4   5   6  
Dizziness  
Physical  

0   1   2   3   4   5   6  
Visual  Problems   0   1   2   3   4   5   6  
Fatigue   0   1   2   3   4   5   6  
Sensitivity  to  Light   0   1   2   3   4   5   6  
Sensitivity  to  Noise   0   1   2   3   4   5   6  
Numbness/Tingling   0   1   2   3   4   5   6  
Pain  other  than  Headache   0   1   2   3   4   5   6  

Feeling  Mentally  Foggy   0   1   2   3   4   5   6  


Thinking  

Feeling  Slowed  Down   0   1   2   3   4   5   6  


Difficulty  Concentrating   0   1   2   3   4   5   6  
Difficulty  Remembering   0   1   2   3   4   5   6  

Drowsiness   0   1   2   3   4   5   6  
Sleep  

Sleeping  Less  than  Usual   0   1   2   3   4   5   6  


Sleeping  More  than  Usual   0   1   2   3   4   5   6  
Trouble  Falling  Asleep   0   1   2   3   4   5   6  
Irritability   0   1   2   3   4   5   6  
Emotional  

Sadness   0   1   2   3   4   5   6  
Nervousness   0   1   2   3   4   5   6  
Feeling  More  Emotional   0   1   2   3   4   5   6  
 
Exertion: Do these symptoms worsen with:
Physical Activity m Yes m No m Not applicable
Thinking/Cognitive Activity m Yes m No m Not applicable
Overall Rating: How different is the person acting compared to his/her usual self?
Same as Usual 0 1 2 3 4 5 6 Very Different
Activity Level: Over the past two days, compared to what I would typically do, my level of activity has
been ______% of what it would be normally.

OCAMP
Oregon Concussion Awareness and Management Program

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