Concussion Patient Self-Assessment: NEW

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Caitlin Stone
6 years ago
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1 Concussion Patient Self-Assessment: NEW Name: Date: Age: Date of Birth: Gender: Male/Female Who referred you to this office?: Height: Weight: Handedness: Right/Left/Ambidextrous Native Country: Primary Language: Secondary Language(if fluent): Details of Current Injury Date of Injury: Sport: Position: How did the injury occur?: Head-head contact Head-body part contact Head-object contact Please describe how the injury occurred and what happened immediately after: Did patient lose consciousness? Yes If yes, how long was the patient unconscious? Was a sideline evaluation performed? Yes If yes, who performed the sideline evaluation? Did the patient continue to participate in the athletic activity after the injury: Yes Has the patient been evaluated by a medical professional since the injury?: Yes If yes, where/by whom?: If yes, were neuroimaging (brain CT or MRI) performed?: Yes If yes, when/where were neuroimaging performed?? Do symptoms worsen with mental activity? Yes If yes, what activities increase symptoms?

2 Since the injury has the patient engaged in: Strenuous exercise? Yes/ If yes, what activity? If yes, did symptoms worsen/recur? Yes/ School attendance? Yes/ If yes, what date did patient return to school?: If yes, is patient attending: Full days? Partial days? Describe current attendance and related issues: Homework? Yes/ If yes, is patient completing regular coursework or modified work load? Describe current workload? If yes, do symptoms worsen/recur during activity? Yes/ Video games? Yes/ If yes, do symptoms worsen/recur during use? Yes/ Computer use (>5min/day)? Yes/ If yes, do symptoms worsen/recur during use? Yes/ Smart phone use (>5min/day)? Yes/ If yes, do symptoms worsen/recur during use? Yes/ Tablet/iPad use (>5min/day)? Yes/ If yes, do symptoms worsen/recur during use? Yes/ Concussion History # of previously diagnosed concussions (excluding current injury) # of concussions resulting in confusion # of concussions that resulted in memory loss for events that occurred immediately AFTER injury # of concussions that resulted in memory loss for events that occurred immediately BEFORE injury # of "dings" previously experienced during or after sport play Total amount of time (days/weeks/months) held out from sports Previous Concussions (Please list all previous concussions) How did the previous concussion(s) occur? Date Recovery Time (Days/Months)

3 Academic History School Name: Current Grade: Academic Performance: Above average Average Below Average Have you ever needed to repeat one or more years of school? Yes Have you ever attended special education classes? Yes Athletic History Current Sport(s): Current Position(s): Level of participation (circle): High school Club Recreational Current Medications: Concussion-Related Medical History Have you ever been diagnosed with: Have you ever been treated for: Autism Yes Chronic Headaches Yes ADD/ADHD Yes Migraine Headaches Yes Learning disability Yes Epilepsy/Seizures Yes Anxiety Yes Meningitis Yes Depression Yes Brain Surgery Yes Bipolar disorder Yes Substance Abuse Yes Other Psychiatric Disorder Yes Psychiatric Condition Yes Sleep Problem Yes Seizure Disorder Yes Are you prone to motion sickness? Yes Other Medical Problem: Yes Have you ever had speech therapy? Yes

4 Immediate Symptoms (0-48 hours post injury) Please report the symptoms experienced by the patient during the first 48 hours after injury. Circle appropriate severity/timing. Symptom Severity Timing Description Memory loss: For events that occurred immediately BEFORE or AFTER injury Disorientation/Confusion Throbbing/pressure/dull Headache Worse AM / PM What makes it worse? "Pressure in head" Neck Pain Dizziness Nausea Vomiting Yes/ How many episodes?_ Balance problems Seizure activity Yes/ How many episodes?_ Numbness/tingling Change in vision (Difficulty seeing, seeing double, seeing spots or any other changes) Sensitivity to light Hearing changes (Ringing in the ears, difficulty hearing or any other changes) Sensitivity to sound "Don't feel right" Feeling slowed down Feeling "in a fog"/ dinged Difficulty remembering Difficulty Concentrating Low Energy/Fatigue Sleep changes Sleeping MORE or LESS than usual? Taking naps? More emotional Easily annoyed or moody Sadness Nervousness/anxiety Other:

5 CURRENT Symptoms (Symptoms you feel TODAY) Please report the symptoms experienced by the patient today on the day of examination. Circle appropriate severity/timing. Symptom Severity Timing Description Memory loss: For events that occurred immediately BEFORE or AFTER injury Disorientation/Confusion Throbbing/pressure/dull Headache Worse AM / PM What makes it worse? "Pressure in head" Neck Pain Dizziness Nausea Vomiting Yes/ How many episodes?_ Balance problems Seizure activity Yes/ How many episodes?_ Numbness/tingling Change in vision (Difficulty seeing, seeing double, seeing spots or any other changes) Sensitivity to light Hearing changes (Ringing in the ears, difficulty hearing or any other changes) Sensitivity to sound "Don't feel right" Feeling slowed down Feeling "in a fog"/ dinged Difficulty remembering Difficulty Concentrating Low Energy/Fatigue Sleep changes Sleeping MORE or LESS than usual? Taking naps? More emotional Easily annoyed or moody Sadness Nervousness/anxiety Other:

POST CONCUSSION SYMPTOM SCALE

POST CONCUSSION SYMPTOM SCALE CONCUSSION INITIAL VISIT FORM Demographics Patient Name: Date of Consultation: DOB: Sex: Age: Who referred you to our clinic? Primary Care Physician: Pharmacy Name/Address: Your E-mail Address: Preferred