Client Intake - ICSS

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	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

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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 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

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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	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

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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	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

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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
SCORE RANGE 0(min symptoms) - 132(max symptoms)
mild 1-21, moderate 22-84

Question Title

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

Question Title

* 2. 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.

Question Title

* 3. 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.

Question Title

* 4. 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.

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* 5. 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.

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* 6. 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 = _______/132SCORE RANGE 0(min symptoms) - 132(max symptoms)mild 1-21, moderate 22-84

* 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.

* 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.

* 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.

* 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.

* 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
SCORE RANGE 0(min symptoms) - 132(max symptoms)
mild 1-21, moderate 22-84