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Concussion Symptom Score Sheet Name Date of injury Circle the number that indicates how much the symptom bothers the patient Date: Symptom Rating Scale Symptom None Mild Mod Date: Date: Symptom Rating.

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Each item is rated on a 5-point ordinal scale: 0 = not experienced at all, 1 = no more of a problem, 2 = a mild problem, 3 = a moderate problem, and 4 = a severe problem. The total score is a sum of all items and ranges from 0 to 64 from (best to worst).

The first few days You may need to take a short time off from work or school, although usually no more than 2 to 3 days. Ask your healthcare for written instructions about when you can safely return to work, school, or other activities, such as driving a car.

Balance problems or dizziness, or double or blurry vision. Bothered by light or noise. Feeling sluggish, hazy, foggy, or groggy. Confusion, or concentration or memory problems.

Immediately following a concussion, you should be examined by a doctor. This can be done at an emergency department or a doctor's office. You should also seek medical attention right away if you have any of the following symptoms within the first few days after the injury: Headache that persists or gets worse over time.

The signs and symptoms of concussion reported within 1 to 7 days post injury (see Table 3-3) typically fall into four categories—physical (somatic), cognitive, emotional (affective), and sleep—and patients will experience one or more symptoms from one or more categories.

An initial score of less than 5 is associated with an 80 percent chance of a lasting vegetative state or death. An initial score of greater than 11 is associated with a 90 percent chance of complete recovery (Teasdale and Jennett, 1974).

Look for: Changes in day-to-day functioning. Eye pain and/or eye fatigue. Headache. Changes in sleep patterns. Neck pain or stiffness. Imbalance, dropping things, bumping into things. Impaired depth perception (having difficulty seeing the distance between two items) Difficulty remembering things.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232