Rivermead

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Rivermead

Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability.

Name *

Date *

YYYY

Headaches *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Feelings of dizziness *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Nausea and/or vomiting *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Noise sensitivity, easily upset by loud noise *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Sleep disturbance *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Fatigue, tiring more easily *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Being irritable, easily angered *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Feeling depressed or tearful *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Feeling frustrated or impatient *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Forgetfulness, poor memory *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Poor concentration *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Taking longer to think *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Blurred vision *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Light sensitivity, easily upset by bright light *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Double vision *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

Restfulness *

0 - Not experienced at all

1 - No more of a problem

2 - A mild problem

3 - A moderate problem

4 - A severe problem

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