Concussion Screening

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Symptom Scale

Please use this scale to rate each of the child's symptoms. 0 = none, 1-2 = mild, 3-4 = moderate, 5-6 severe.

Headache:
Nausea:
Vomiting:
Balance Problems:
Diziness (spinning or movement sensation):
Lightheadedness:
Fatigue:
Trouble falling asleep:
Sleeping more than usual:
Sleeping less than usual:
Drowsiness:
Sensitivity to light:
Sensitivity to sound:
Irritability:
Sadness:
Nervous/Anxious:
Feeling more emotional:
Numbness or tingling:
Feeling slowed down:
Feeling like "in a fog":
Difficulty concentrating:
Difficulty Remembering:
Visual problems: