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