"Post-concussion Symptom Checklist Template - Ocamp"

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P
-C
S
CHeCKliST
OST
OnCuSSiOn
YmPTOm
Name: ___________________________
Date: ____/____/______
Instructions: For each item please indicate how much the symptom has bothered you over the past 2 days
Symptoms  
none  
mild  
moderate  
severe  
Headache  
0  
1  
2  
3  
4  
5  
6  
Nausea  
0  
1  
2  
3  
4  
5  
6  
Vomiting  
0  
1  
2  
3  
4  
5  
6  
Balance   P roblem  
0  
1  
2  
3  
4  
5  
6  
Dizziness  
0  
1  
2  
3  
4  
5  
6  
Visual   P roblems  
0  
1  
2  
3  
4  
5  
6  
Fatigue  
0  
1  
2  
3  
4  
5  
6  
Sensitivity   t o   L ight  
0  
1  
2  
3  
4  
5  
6  
Sensitivity   t o   N oise  
0  
1  
2  
3  
4  
5  
6  
Numbness/Tingling  
0  
1  
2  
3  
4  
5  
6  
Pain   o ther   t han   H eadache  
0  
1  
2  
3  
4  
5  
6  
Feeling   M entally   F oggy  
0  
1  
2  
3  
4  
5  
6  
Feeling   S lowed   D own  
0  
1  
2  
3  
4  
5  
6  
Difficulty   C oncentrating  
0  
1  
2  
3  
4  
5  
6  
Difficulty   R emembering  
0  
1  
2  
3  
4  
5  
6  
Drowsiness  
0  
1  
2  
3  
4  
5  
6  
Sleeping   L ess   t han   U sual  
0  
1  
2  
3  
4  
5  
6  
Sleeping   M ore   t han   U sual  
0  
1  
2  
3  
4  
5  
6  
Trouble   F alling   A sleep  
0  
1  
2  
3  
4  
5  
6  
Irritability  
0  
1  
2  
3  
4  
5  
6  
Sadness  
0  
1  
2  
3  
4  
5  
6  
Nervousness  
0  
1  
2  
3  
4  
5  
6  
 
Feeling   M ore   E motional  
0  
1  
2  
3  
4  
5  
6  
Exertion: Do these symptoms worsen with:
Physical Activity
m Yes m No m Not applicable
Thinking/Cognitive Activity m Yes m No m Not applicable
Overall Rating: How different is the person acting compared to his/her usual self?
Same as Usual
0
1
2
3
4
5
6
Very Different
Activity Level: Over the past two days, compared to what I would typically do, my level of activity has
been ______% of what it would be normally.
OCAMP
Oregon Concussion Awareness and Management Program
P
-C
S
CHeCKliST
OST
OnCuSSiOn
YmPTOm
Name: ___________________________
Date: ____/____/______
Instructions: For each item please indicate how much the symptom has bothered you over the past 2 days
Symptoms  
none  
mild  
moderate  
severe  
Headache  
0  
1  
2  
3  
4  
5  
6  
Nausea  
0  
1  
2  
3  
4  
5  
6  
Vomiting  
0  
1  
2  
3  
4  
5  
6  
Balance   P roblem  
0  
1  
2  
3  
4  
5  
6  
Dizziness  
0  
1  
2  
3  
4  
5  
6  
Visual   P roblems  
0  
1  
2  
3  
4  
5  
6  
Fatigue  
0  
1  
2  
3  
4  
5  
6  
Sensitivity   t o   L ight  
0  
1  
2  
3  
4  
5  
6  
Sensitivity   t o   N oise  
0  
1  
2  
3  
4  
5  
6  
Numbness/Tingling  
0  
1  
2  
3  
4  
5  
6  
Pain   o ther   t han   H eadache  
0  
1  
2  
3  
4  
5  
6  
Feeling   M entally   F oggy  
0  
1  
2  
3  
4  
5  
6  
Feeling   S lowed   D own  
0  
1  
2  
3  
4  
5  
6  
Difficulty   C oncentrating  
0  
1  
2  
3  
4  
5  
6  
Difficulty   R emembering  
0  
1  
2  
3  
4  
5  
6  
Drowsiness  
0  
1  
2  
3  
4  
5  
6  
Sleeping   L ess   t han   U sual  
0  
1  
2  
3  
4  
5  
6  
Sleeping   M ore   t han   U sual  
0  
1  
2  
3  
4  
5  
6  
Trouble   F alling   A sleep  
0  
1  
2  
3  
4  
5  
6  
Irritability  
0  
1  
2  
3  
4  
5  
6  
Sadness  
0  
1  
2  
3  
4  
5  
6  
Nervousness  
0  
1  
2  
3  
4  
5  
6  
 
Feeling   M ore   E motional  
0  
1  
2  
3  
4  
5  
6  
Exertion: Do these symptoms worsen with:
Physical Activity
m Yes m No m Not applicable
Thinking/Cognitive Activity m Yes m No m Not applicable
Overall Rating: How different is the person acting compared to his/her usual self?
Same as Usual
0
1
2
3
4
5
6
Very Different
Activity Level: Over the past two days, compared to what I would typically do, my level of activity has
been ______% of what it would be normally.
OCAMP
Oregon Concussion Awareness and Management Program