Symptom Checklist
2-3 Hrs
24 Hrs
48 Hrs
72 Hrs
Daily
Weekly
| Symptoms | Severity Rating | ||||||
|---|---|---|---|---|---|---|---|
| None | Mild | Moderate | Severe | ||||
| I feel like I'm going to faint | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I'm having trouble balancing | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel dizzy | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| It feels like the room is spinning | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| Things look blurry | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I see double | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I have headaches | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel sick to my stomach (nauseated) | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| Noise/sound bothers me | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| The light bothers my eyes | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I have pressure in my head | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel numbness and tingling | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I have neck pain | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I have trouble falling asleep | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel like sleeping too much | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel like I am not getting enough sleep | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I have low energy (fatigue) | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel tired a lot (drowsiness) | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I have trouble paying attention | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I am easily distracted | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I have trouble concentrating | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I have trouble remembering things | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I have trouble following directions | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel like my thinking is "foggy" | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel like I am moving at a slower speed | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I don't feel "right" | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel confused | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I have trouble learning new things | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel more emotional | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel sad | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel nervous | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| I feel irritable or grouchy | 0 | 1 | 2 | 3 | 4 | 5 | 6 |
| Other: _______________________________________________________________ | |||||||
| Weekly symptom progress monitoring is recommended as best practice. | |||||||
Concussion Navigator includes an interactive symptom checklist where you can also track recovery after an incident. Alternatively, you can download the above symptom checklist here.