Page 17

APPENDIX

Symptom Checklist Name: ________________________________________________ Date of Injury: _______________________________________ Time of Injury

Assessment Date: ____________________________________________

2-3 Hrs

24 Hrs

Mild

Mild

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

O H

C N S/E

Cog

E

I feel like I’m going to faint I’m having trouble balancing I feel dizzy It feels like the room is spinning Things look blurry I see double I have headaches I feel sick to my stomach (nauseated) Noise/sound bothers me The light bothers my eyes I have pressure in my head I feel numbness and tingling I have neck pain I have trouble falling asleep I feel like sleeping too much I feel like I am not getting enough sleep I have low energy (fatigue) I feel tired a lot (drowsiness) I have trouble paying attention I am easily distracted I have trouble concentrating I have trouble remembering things I have trouble following directions I feel like my thinking is ”foggy” I feel like I am moving at a slower speed I don’t feel “right” I feel confused I have trouble learning new things I feel more emotional I feel sad I feel nervous I feel irritable or grouchy

Daily

Weekly

Moderate

Moderate

Severe

Severe

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

SEVERITY RATING

Pathways Symptoms

A V

72 Hrs

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Other: ______________________________________________________________________________________________________________________________________________________

Pathways of concern: A=Autonomic V=Vestibular O=Oculomotor H=Headache (Migraine &Non-Migraine) C=Cervicogenic N=Neck Strain S/E=Sleep/Energy Cog=Cognitive E=Emotional

© 2013 HCA HealthONE

SYMPTOMS

48 Hrs

Profile for HealthONE

REAP Concussion Management Program  

REAP helps families, schools and medical professionals develop a multidisciplinary team around the student athlete to help ensure their reco...

REAP Concussion Management Program  

REAP helps families, schools and medical professionals develop a multidisciplinary team around the student athlete to help ensure their reco...

Profile for healthone
Advertisement