Cif Graded Concussion Symptom Checklist
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1CIF GRADED CONCUSSION SYMPTOM CHECKLIST
Today’s Date: _______________
Time: _______________
Hours of Sleep: _______________
Date of Diagnosis: _______________
Grade the 22 symptoms with a score of 0 through 6.
☐ Baseline Score
o Note that these symptoms may not all be related to a concussion.
☐ Post Concussion Score
You can fill this out at the beginning of the season as a baseline (after a good night’s sleep).
If you suffer a suspected concussion, use this checklist to record your symptoms daily.
o Be consistent and try to grade either at the beginning or end of each day.
There is no scale to compare your total score to; this checklist helps you follow your symptoms on a day-to-day basis.
o If your total scores are not decreasing, see your physician right away.
Show your baseline (if available) and daily checklists to your physician.
None
Mild
Moderate
Severe
Headache
0
1
2
3
4
5
6
“Pressure in head”
0
1
2
3
4
5
6
Neck Pain
0
1
2
3
4
5
6
Nausea or Vomiting
0
1
2
3
4
5
6
Dizziness
0
1
2
3
4
5
6
Blurred Vision
0
1
2
3
4
5
6
Balance Problems
0
1
2
3
4
5
6
Sensitivity to light
0
1
2
3
4
5
6
Sensitivity to noise
0
1
2
3
4
5
6
Feeling slowed down
0
1
2
3
4
5
6
Feeling like “in a fog”
0
1
2
3
4
5
6
“Don't feel right”
0
1
2
3
4
5
6
Difficulty concentrating
0
1
2
3
4
5
6
Difficulty remembering
0
1
2
3
4
5
6
Fatigue or low energy
0
1
2
3
4
5
6
Confusion
0
1
2
3
4
5
6
Drowsiness
0
1
2
3
4
5
6
Trouble falling asleep
0
1
2
3
4
5
6
More emotional than usual
0
1
2
3
4
5
6
Irritability
0
1
2
3
4
5
6
Sadness
0
1
2
3
4
5
6
Nervous or Anxious
0
1
2
3
4
5
6
TOTAL SUM OF EACH COLUMN
0
TOTAL SYMPTOM SCORE (Sum of all column totals)
NAME _______________________________________
HIGH SCHOOL __________________________________
D.O.B. _____________
SPORT _________________
PHYSICIAN (MD/DO) _____________________________
CIF 5/2015
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