ImPACT Post Concussion Symptom Scale

Question Title

* 1. Please type your name. Surname, First Name

Question Title

* 2. Who is your Physiotherapist?

Question Title

* 3. PHYSICAL SYMPTOMS

Since the Injury, have you experienced any of the following symptoms, any more than usual, today or in the past day? Please choose a level for each symptom.

  0 none 1 2 3 4 5 6 severe
Headache
Nausea
Vomiting
Balance Problems
Dizziness
Visual Problems
Fatigue
Sensitivity to light
Sensitivity to noise
Numbness/Tingling

Question Title

* 4. COGNITIVE SYMPTOMS

Since the Injury, have you experienced any of the following symptoms, any more than usual, today or in the past day? Please choose a level for each symptom.

  0 none 1 2 3 4 5 6 severe
Feeling mentally foggy
Feeling slowed down
Difficulty concentrating
Difficulty remembering

Question Title

* 5. EMOTIONAL SYMPTOMS

Since the Injury, have you experienced any of the following symptoms, any more than usual, today or in the past day? Please choose a level for each symptom.

  0 none 1 2 3 4 5 6
Irritability
Sadness
More emotional
Nervousness

Question Title

* 6. SLEEP SYMPTOMS

Since the Injury, have you experienced any of the following symptoms, any more than usual, today or in the past day? Please choose a level for each symptom.

  0 none 1 2 3 4 5 6 severe
Drowsiness
Sleeping less than usual
Sleeping more than usual
Trouble falling asleep

Question Title

* 7. Interpretation of scores (for office use only)

PHYSICAL SCORE = _____/60
COGNITIVE SCORE = _____/24
EMOTIONAL SCORE = _____/24
SLEEP SCORE = _____/24

TOTAL SCORE: add up the total scores = _______/132
0(min symptoms)-132(max symptoms)
mild 1-21, moderate 22-84

T