"Concussion Symptoms Checklist Template - Providence Health & Service"

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Concussion: Symptom Tracking Sheet
Athlete’s name: __________________________________ _ ____________________________ Date of birth: _____ /_____ /_____ Age/grade: ____/_____
Date of injury: _____________
Documentation completed by: _________________ _____________________
Graded Symptoms Checklist
Activity tried
(e.g., reading, walking, jogging)
Date/Time: Date/Time: Date/Time: Date/Time: Date/Time: Date/Time: Date/Time: Date/Time: Date/Time: Date/Time:
Headache
Pressure in head
Neck pain
Nausea or vomiting
Dizziness
Blurred vision
Balance problems
Sensitivity to light
Sensitivity to noise
Feel slowed down
Feel like “in a fog”
Don’t feel “right”
concentration
memory
Fatigue/low energy
Confusion
Drowsiness
Difficulty sleeping
More emotional
Irritability
Sadness
Nervous/anxious
Comments:
This information is provided by Providence Health & Services
and our sports concussion specialists.
providenceoregon.org/concussion
PH16-20096D
Concussion: Symptom Tracking Sheet
Athlete’s name: __________________________________ _ ____________________________ Date of birth: _____ /_____ /_____ Age/grade: ____/_____
Date of injury: _____________
Documentation completed by: _________________ _____________________
Graded Symptoms Checklist
Activity tried
(e.g., reading, walking, jogging)
Date/Time: Date/Time: Date/Time: Date/Time: Date/Time: Date/Time: Date/Time: Date/Time: Date/Time: Date/Time:
Headache
Pressure in head
Neck pain
Nausea or vomiting
Dizziness
Blurred vision
Balance problems
Sensitivity to light
Sensitivity to noise
Feel slowed down
Feel like “in a fog”
Don’t feel “right”
concentration
memory
Fatigue/low energy
Confusion
Drowsiness
Difficulty sleeping
More emotional
Irritability
Sadness
Nervous/anxious
Comments:
This information is provided by Providence Health & Services
and our sports concussion specialists.
providenceoregon.org/concussion
PH16-20096D