Pre-appointment questionnaire for concussion patients Step 1 of 5 20% The Purpose Of This Questionnaire We would like you to fill in this questionnaire before you arrive for your first appointment to: help you to reflect on how your concussion has impacted your life. enable you to give us the information we need to treat concussion effectively. Name* D.O.B* DD slash MM slash YYYY Email* 1. AFFECTED AREASWhat areas of function have been affected by your concussion?* Neck pain Eye movement Fitness/Fatigue Anxiety Vertigo Balance Concentration Migraine 2. HISTORYHave you had more than one concussion?* When was your most recent concussion?* What areas of your life have been affected?* Home Work School Recreation Sport Other Other: Are there any limitations that are concerning you?* What severity range are your symptoms? Mark on scale below.Your worst symptoms?Your least symptoms? 3. PRESENTATION OF SYMPTOMSWhat things always make your symptoms worse?* What medications do you use and how often?* Are there any other relieving factors?* What do you do when you get your worst symptoms?* After a head injury or accident some people experience symptoms which can cause worry or nuisance. We would like to know if you now ( ie. in the last 24 hours) suffer from any of the symptoms given below. If you are filling this out on behalf of someone, please allow them to complete this section on their own. For each one, please select the number closest to your answer. 0 = Pain-free 1 = Very mild 2 = Mild 3 = Moderate 4 = Moderately strong 5 = Severe 6 = Excruciating Compared with before the accident, do you now (i.e., over the last 24 hours) suffer from: Headache* 0 1 2 3 4 5 6 'Pressure in head'* 0 1 2 3 4 5 6 Neck pain* 0 1 2 3 4 5 6 Nausea or vomiting* 0 1 2 3 4 5 6 Dizziness* 0 1 2 3 4 5 6 Blurred vision* 0 1 2 3 4 5 6 Balance problems* 0 1 2 3 4 5 6 Sensitivity to light* 0 1 2 3 4 5 6 Sensitivity to noise* 0 1 2 3 4 5 6 Feeling slowed down* 0 1 2 3 4 5 6 Feeling like "in a fog"* 0 1 2 3 4 5 6 'Don't feel right'* 0 1 2 3 4 5 6 Difficulty concentrating* 0 1 2 3 4 5 6 Difficulty remembering* 0 1 2 3 4 5 6 Fatigue or low energy* 0 1 2 3 4 5 6 Confusion* 0 1 2 3 4 5 6 Drowsiness* 0 1 2 3 4 5 6 More emotional* 0 1 2 3 4 5 6 Irritability* 0 1 2 3 4 5 6 Sadness* 0 1 2 3 4 5 6 Nervous or Anxious* 0 1 2 3 4 5 6 Trouble falling asleep* 0 1 2 3 4 5 6 Are you experiencing any other difficulties? Other? 0 1 2 3 4 5 6 Any more difficulties? Other? 0 1 2 3 4 5 6 HiddenTotal HIT
