Post-Concussion Symptom Evaluation

Full Name *

Date *

1. Headache *

(0) None, (1) Mild, (2) Mild, (3) Moderate, (4) Moderate (5) Severe, (6) Severe

2. "Pressure" in head *

3. Neck pain *

4. Nausea or vomiting *

5. Dizziness *

6. Blurred vision *

7. Balance problems *

8. Sensitivity to light *

9. Sensitivity to noise *

10. Feeling slowed down *

11. Feeling like "in a fog" *

12. "Don't feel right" *

13. Difficulty concentrating *

14. Difficulty remembering *

15. Fatigue or low energy *

16. Confusion *

17. Drowsiness *

18. More emotional *

19. Irritability *

20. Sadness *

21. Nervous or Anxious *

22. Trouble falling asleep (if applicable) *

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Brain, Not Bone Alone

Get in Touch

Email:

[email protected]

Address:
26302 La Paz Road, Suite 214

Mission Viejo, CA 92691

Phone Number:

Call Office : 949-359-8385

Text Office: 949-619-6545

Hours of Operation

Monday | 9:00am – 5:30pm

Tuesday | 9:00am – 5:30pm

Wednesday | 7:30am – 11:30am

Thursday | 9:00am – 5:30pm

Friday | Closed

Sat & Sun | Closed

26302 La Paz Road, Suite 214

Mission Viejo, CA 92691

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