Instructions:
Enter your Date-of-Birth, Date-of-Injury and age in the appropriate fields.
All questions are yes or no.
Do not leave any questions unanswered.
Date-of-Birth
Date-of-Injury
Age
Have you restricted your own social activity?
Yes
No
Do you experience nausea in a car or a busy environment?
Yes
No
Do you experience difficulty going from focusing on something nearby to something far away?
Yes
No
Do you have a diagnosed learning disability?
Yes
No
Are you able to stare up at the ceiling for five seconds without pain or increase of symptoms?
Yes
No
Does math or science class make your symptoms worse?
Yes
No
Do you have neck pain at rest?
Yes
No
Do you experience unstable or blurry vision?
Yes
No
Have you experienced excessive fatigue?
Yes
No
Has your diet or hydration changed since your injury?
Yes
No
Is there a specific environment where your symptoms get worse?
Yes
No
Do your symptoms get worse when you think about them or your recovery?
Yes
No
Do you experience a headache behind your eyes?
Yes
No
Do you experience increased headache with reading or mental activity?
Yes
No
If you experience dizziness, does it feel slow and lazy?
Yes
No
Do you feel as if you are being "pushed" too hard in academics or athletics?
Yes
No
If you experience dizziness, does it feel rapid or as if the room is spinning?
Yes
No
Do your symptoms get worse with neck movement?
Yes
No
Do lights and/or screens make your symptoms worse?
Yes
No
Have you experienced too much or too little sleep since your injury?
Yes
No
If you experience dizziness, do you also experience feeling disoriented?
Yes
No
Do you spend a lot of time thinking about your symptoms?
Yes
No
Do you feel "one step behind?"
Yes
No
Do you feel excessively tired?
Yes
No
Do you have a family history of migraines?
Yes
No
Have you experienced increased stress?
Yes
No
Have you or anyone in your family been diagnosed with a "lazy eye?"
Yes
No
After cognitive activity (reading, answering questions, critical thinking, etc) do you experience difficulty focusing or thinking?
Yes
No
Do you "crash" or feel significantly worse at the end of the day?
Yes
No
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