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The Post Concussion Symptom Scale

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 45601234560123456012345601234560123456 Grand Total of all Symptoms: Comments: SymptomMildModerateSevereHeadachesIrrita tionNauseaVomitingBalance ProblemsDizzinessFatigueTrouble Falling AsleepSleeping LongerSleeping LessDrowsinessIntolerance to LightIntolerance to NoiseDifficulty ConcentratingDifficulty RememberingVisual ProblemsTOTAL Symptom SCORES adnessNervousnessStronger EmotionsNumbness or TinglingMentally SlowerMentally Blurr

Name: _____ Date: _____ Date of last known concussion(s): _____ The Post Concussion Symptom Scale

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Transcription of The Post Concussion Symptom Scale

1 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 45601234560123456012345601234560123456 Grand Total of all Symptoms: Comments: SymptomMildModerateSevereHeadachesIrrita tionNauseaVomitingBalance ProblemsDizzinessFatigueTrouble Falling AsleepSleeping LongerSleeping LessDrowsinessIntolerance to LightIntolerance to NoiseDifficulty ConcentratingDifficulty RememberingVisual ProblemsTOTAL Symptom SCORES adnessNervousnessStronger EmotionsNumbness or TinglingMentally SlowerMentally Blurr


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