ICSS + PSFS ImPACT Post Concussion Symptom Scale Question Title * 1. Please type your name. Surname, First Name Question Title * 2. Who is your Physiotherapist? Mandi Hayes Jennifer Duke Anthony Giorgianni Jeanine Stott Beata Sadowska Heather Clegg Chris Cosby I cannot remember Question Title * 3. PHYSICAL SYMPTOMSSince 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 Headache 0 none Headache 1 Headache 2 Headache 3 Headache 4 Headache 5 Headache 6 severe Nausea Nausea 0 none Nausea 1 Nausea 2 Nausea 3 Nausea 4 Nausea 5 Nausea 6 severe Vomiting Vomiting 0 none Vomiting 1 Vomiting 2 Vomiting 3 Vomiting 4 Vomiting 5 Vomiting 6 severe Balance Problems Balance Problems 0 none Balance Problems 1 Balance Problems 2 Balance Problems 3 Balance Problems 4 Balance Problems 5 Balance Problems 6 severe Dizziness Dizziness 0 none Dizziness 1 Dizziness 2 Dizziness 3 Dizziness 4 Dizziness 5 Dizziness 6 severe Visual Problems Visual Problems 0 none Visual Problems 1 Visual Problems 2 Visual Problems 3 Visual Problems 4 Visual Problems 5 Visual Problems 6 severe Fatigue Fatigue 0 none Fatigue 1 Fatigue 2 Fatigue 3 Fatigue 4 Fatigue 5 Fatigue 6 severe Sensitivity to light Sensitivity to light 0 none Sensitivity to light 1 Sensitivity to light 2 Sensitivity to light 3 Sensitivity to light 4 Sensitivity to light 5 Sensitivity to light 6 severe Sensitivity to noise Sensitivity to noise 0 none Sensitivity to noise 1 Sensitivity to noise 2 Sensitivity to noise 3 Sensitivity to noise 4 Sensitivity to noise 5 Sensitivity to noise 6 severe Numbness/Tingling Numbness/Tingling 0 none Numbness/Tingling 1 Numbness/Tingling 2 Numbness/Tingling 3 Numbness/Tingling 4 Numbness/Tingling 5 Numbness/Tingling 6 severe Question Title * 4. COGNITIVE SYMPTOMSSince 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 mentally foggy 0 none Feeling mentally foggy 1 Feeling mentally foggy 2 Feeling mentally foggy 3 Feeling mentally foggy 4 Feeling mentally foggy 5 Feeling mentally foggy 6 severe Feeling slowed down Feeling slowed down 0 none Feeling slowed down 1 Feeling slowed down 2 Feeling slowed down 3 Feeling slowed down 4 Feeling slowed down 5 Feeling slowed down 6 severe Difficulty concentrating Difficulty concentrating 0 none Difficulty concentrating 1 Difficulty concentrating 2 Difficulty concentrating 3 Difficulty concentrating 4 Difficulty concentrating 5 Difficulty concentrating 6 severe Difficulty remembering Difficulty remembering 0 none Difficulty remembering 1 Difficulty remembering 2 Difficulty remembering 3 Difficulty remembering 4 Difficulty remembering 5 Difficulty remembering 6 severe Question Title * 5. EMOTIONAL SYMPTOMSSince 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 Irritability 0 none Irritability 1 Irritability 2 Irritability 3 Irritability 4 Irritability 5 Irritability 6 Sadness Sadness 0 none Sadness 1 Sadness 2 Sadness 3 Sadness 4 Sadness 5 Sadness 6 More emotional More emotional 0 none More emotional 1 More emotional 2 More emotional 3 More emotional 4 More emotional 5 More emotional 6 Nervousness Nervousness 0 none Nervousness 1 Nervousness 2 Nervousness 3 Nervousness 4 Nervousness 5 Nervousness 6 Question Title * 6. SLEEP SYMPTOMSSince 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 Drowsiness 0 none Drowsiness 1 Drowsiness 2 Drowsiness 3 Drowsiness 4 Drowsiness 5 Drowsiness 6 severe Sleeping less than usual Sleeping less than usual 0 none Sleeping less than usual 1 Sleeping less than usual 2 Sleeping less than usual 3 Sleeping less than usual 4 Sleeping less than usual 5 Sleeping less than usual 6 severe Sleeping more than usual Sleeping more than usual 0 none Sleeping more than usual 1 Sleeping more than usual 2 Sleeping more than usual 3 Sleeping more than usual 4 Sleeping more than usual 5 Sleeping more than usual 6 severe Trouble falling asleep Trouble falling asleep 0 none Trouble falling asleep 1 Trouble falling asleep 2 Trouble falling asleep 3 Trouble falling asleep 4 Trouble falling asleep 5 Trouble falling asleep 6 severe Question Title * 7. Interpretation of scores (for office use only)PHYSICAL SCORE = _____/60 COGNITIVE SCORE = _____/24 EMOTIONAL SCORE = _____/24 SLEEP SCORE = _____/24TOTAL SCORE: add up the total scores = _______/132 SCORE RANGE: 0(min symptoms)-132(max symptoms) mild 1-21, moderate 22-84 Next
