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Concussion Symptom Checklist  Form

Concussion Symptom Checklist Form

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Blurred Vision Balance Problems Sensitivity to light Feeling slowed down Feeling like in a fog Don t feel right Difficulty concentrating Difficulty remembering Fatigue or low energy Confusion Drowsiness Trouble falling asleep More emotional than usual Irritability Sadness Nervous or Anxious TOTAL SUM OF EACH COLUMN TOTAL SYMPTOM SCORE Sum of all column totals NAME HIGH SCHOOL D. O Note that these symptoms may not all be related to a concussion. Baseline Score Post Concussion Score You can...
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