ImPACT Post Concussion Symptom Scale

Welcome to Resolution Physiotherapy & IMS Clinic and thank you for choosing our team of Physiotherapists to help resolve your pain. We look forward to meeting you and showing you how effective our team of highly qualified Physiotherapists can be.

Please complete this questionnaire if our Physiotherapists are treating you following a concussion.

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

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* 2. 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

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* 3. 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

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* 4. 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

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* 5. 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

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* 6. 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

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