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The Post Concussion Symptom Scale

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Name: ___________________________________Date: ______________Date of last known Concussion (s): ________________________________________ ________________The post Concussion Symptom ScaleReport your current experience of symptoms. After reading each Symptom , please circle the number thatbest describes the way you have been feeling today. A rating of 0 means that you have not experienced this Symptom today. A rating of 6 means that you have experienced severe problems with this Symptom today. None012345601234560123456012345601234560 1234560123456012345601234560123456012345 6012345601234560123456012345601234560123 45601234560123456012345601234560123456Gr and Total of all Symptoms: Comments: SymptomMildModerateSevereHeadachesIrrita tionNauseaVomitingBalance ProblemsDizzinessFatigueTrouble Falling AsleepSleeping LongerSleeping LessDrowsinessIntolerance to LightIntolerance to NoiseDifficulty ConcentratingDifficulty RememberingVisual ProblemsTOTAL Symptom SCORESadnessNervousnessStronger EmotionsNumbness or TinglingMentally SlowerMentally Blurr

The Post Concussion Symptom Scale Report your current experience of symptoms. After reading each symptom, please circle the number that best describes the way you have been feeling today. A rating of 0 means that you have not experienced this symptom today. A rating of 6 means that you have experienced severe problems with this symptom today.

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