Concussion Questions
Full Name *
Date of Birth *
MM
/
DD
/
GGGG
Cognitive/Fatigue:
If you get headaches, do they increase as the day progresses? *
Are you feeling more tired at the end of the day than normal? *
Are you more distracted at work/school than normal? *
Do you find yourself skipping lines while reading? *
Anything else you want to let us know about the above regarding cognition/fatigue? *
Vestibular:
Do quick movements make you dizzy, foggy, anxious? *
Do busy environments cause you to have a headache or feel foggy, dizzy, anxious, or tired? *
Do you become dizzy when looking up/down, turning head, walking down busy hallways? *
Anything else you want to let us know about the above regarding vestibular symptoms? *
Oculomotor:
Do you feel frontal pressure in your head/behind your eyes with visual work? *
Are you having more trouble in math and/or science than other subjects? *
Are you experiencing blurred or fuzzy vision while reading or difficulty reading? *
Have you had to change your preferred sitting location in class? *
Anything else you want to let us know about the above regarding vision and visual work? *
Anxiety/Mood:
Do you spend a lot of time thinking about your injury and current symptoms? *
Are you having symptoms during downtime when you are alone? *
Are you having any difficulties falling asleep? *
Do your family/friends/co-workers/significant other ask you about your symptoms often? *
Anything else you want to let us know about the above regarding anxiety/mood? *
Migraine:
Do you have a history of migraine headaches prior to injury? *
Do you have a headache in the morning after a poor night's sleep? *
Do you have dysregulated sleep? *
Have you noticed any visual changes before or during your headaches? *
Do you become sensitive to normal room light or noise during your headache? *
Anything else you want to let us know about the above regarding migraine symptoms? *
Cervical:
Do you have neck pain? *
When you get your headache, where does it start? *
Are there certain neck movements or postures that will cause your headache? *
Do you have a history of neck injury or MVA? *
Was your head whipped around at the time of injury? *
Anything else you want to let us know about the above regarding neck symptoms? *
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