Post-Concussion Symptom

None	Mild		Moderate		Severe
0	1	2	3	4	5	6
Concussion Symptom PHYSICAL SYMPTOMS * 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 Problems* 0 1 2 3 4 5 6 Dizziness* 0 1 2 3 4 5 6 Blurry or Double Vision* 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 Hearing Changes* 0 1 2 3 4 5 6 Ringing in Ears* 0 1 2 3 4 5 6 Change in Smell* 0 1 2 3 4 5 6 Change in Taste* 0 1 2 3 4 5 6 Slurred Speech* 0 1 2 3 4 5 6 Face Pain* 0 1 2 3 4 5 6 COGNITIVE SYMPTOMS * Difficulty Concentrating* 0 1 2 3 4 5 6 Difficulty Remembering* 0 1 2 3 4 5 6 Slowed Thinking* 0 1 2 3 4 5 6 SLEEP SYMPTOMS Trouble falling asleep* 0 1 2 3 4 5 6 Difficulty Staying Asleep* 0 1 2 3 4 5 6 Drowsiness* 0 1 2 3 4 5 6 Fatigue or Low Energy* 0 1 2 3 4 5 6 EMOTIONAL SYMPTOMS * Feeling more Emotional* 0 1 2 3 4 5 6 Irritablility* 0 1 2 3 4 5 6 Sadness and Depression* 0 1 2 3 4 5 6 Anxiety and Nervousness* 0 1 2 3 4 5 6 Anger* 0 1 2 3 4 5 6 Number First Last * * Date Format: MM slash DD slash YYYY * Date Format: MM slash DD slash YYYY

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Post-Concussion Symptom

Concussion Symptom

PHYSICAL SYMPTOMS *

COGNITIVE SYMPTOMS *

SLEEP SYMPTOMS

EMOTIONAL SYMPTOMS *