ASW Concussion Symptom Score Sheet
Student,

Please complete this online form everyday while you are home from school with your head injury. Follow up with the ASW Health Office once you are feeling well enough to return to school.

Please honestly rate how you're currently feeling on a scale of 0-6.
0 = No Symptom
6 = Severe Symptom
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電子郵件 *
Family name *
First name *
Headache or “pressure” in head *
None
Severe
Nausea or vomiting *
None
Severe
Balance problems, light-headed or dizzy *
None
Severe
Fatigue or feeling tired *
None
Severe
Blurry or double vision *
None
Severe
Sensitivity to light *
None
Severe
Sensitivity to noise *
None
Severe
Numbness or tingling *
None
Severe
Does not “feel right” *
None
Severe
Difficulty thinking clearly *
None
Severe
Difficulty concentrating *
None
Severe
Difficulty remembering *
None
Severe
Feeling more slowed down than usual *
None
Severe
Feeling sluggish, hazy, foggy, or groggy *
None
Severe
Nervous, anxiousness, irritable, emotional or saf *
None
Severe
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