Neuro symptom checklist

Concussion Checklist

Please fill out each question below rating your symptoms in severity where 0 = no symptoms, 1 – 2 = Mild, 3 – 4 = Moderate, 5 – 6 = Severe

Name
Name
First
Last
Headache
Pressure in the Head
Nausea or Vomiting
Dizziness
Blurred vision
Balance problems
Sensitivity to light
Sensitivity to noise
Feeling slowed down
Feeling in a fog
‘Don’t feel right’
Difficulty concentrating
Difficulty remembering
Fatigue or low energy
Confusion
Drowsiness
Trouble falling asleep
More emotional
Irritability
Sadness
Nervous or anxious
Sleeping more than usual
Difficulty sleeping soundly
Ringing in the ears
Numbness or tingling
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