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Concussion Survey
Jared Larsen
2020-09-24T20:23:16+00:00
Concussion Survey
Concussion Survey
Step
1
of
10
10%
Name
*
Name
First
Last
Please select your case manager
*
Please select your case manager
Choose one
Alma Orozco
Ashley Orozco
Bree Campbell
Brenda Rodriguez
Chase Dunakin
Chase Hebdon
Cindy Joyner
Elizabeth Miller
Hailey Moore
Jared Larsen
Jose Nava
Josh Esteron
Lucero Sanchez
Luis Cruz
Maria Martinez
Michele Mesaros
Monica Guerrero
Nathan Perdue
Veronica Barajas
Other
Check any symptoms experienced immediately following the accident or injury
Check any symptoms experienced immediately following the accident or injury
Double vision
Headache
Blurred vision
Pain in or around eyes
Dizziness
Vomiting
Flashes of light
Disorientation / fogginess
Loss of balance
Loss of memory
Neck pain / whiplash
Restricted field of view
Restricted motion
Loss of consciousness
Coma
Check any symptoms currently being experienced
Check any symptoms currently being experienced
Blurred Vision - Distance
Blurred Vision - Near
Eyes ache
Pain in or around eyes
Headaches
Eye redness
Watery eyes
Pain with eye movement
Eyes twitch
Itchy eyes
Check any symptoms currently being experienced
Check any symptoms currently being experienced
Difficult moving or turning eyes
Difficulty changing focus far to near
Motion sickness / car sickness
Double vision
Light sensitivity
Objects moving in environment is bothersome
Head moves when reading
One eye turns in, out, up or down
See overlapping or shadowed image
Squinting, covering or closing one eye
Check any symptoms currently being experienced
Check any symptoms currently being experienced
Lose place often when reading
Words jump or move around when reading
Short attention span reading or writing
Skip words frequently when reading
Discomfort when reading
Have difficulty following moving targets
Use a finger or an underliner when reading
Orients writing /drawing poorly on page
Hold books too close
Avoid reading or writing
Check any symptoms currently being experienced
Check any symptoms currently being experienced
Head tilts during desk work
Difficulty with peripheral vision
Flashes of light
Objects jump in and out of field of view
Reduced depth perception
Tunnel vision / loss of visual field
Trip or fall / poor balance
Trouble seeing at night
Often knock things over
Bump into things, objects, chairs, or walls
Check any symptoms currently being experienced
Check any symptoms currently being experienced
Clumsiness
Difficulty with dressing
Portions of objects /pages ever missing
Startled by people or objects
Dizziness
Hold things, walls, people when walking
Difficult bathing/personal hygiene
Difficulty following series of directions
Get lost often
Confusion / disorientation
Check any symptoms currently being experienced
Check any symptoms currently being experienced
Confusion / disorientation
Bothered by noises
Difficulty remembering things seen
Difficulty with numbers
Difficulty using both sides of body together
Difficulty remembering things heard
Difficulty with time management
Difficulty remembering name of objects
Difficulty remembering people’s names
Difficulty recalling info known in past
Difficulty remembering former familiar people/objects
Difficult performing tasks formerly easy /routine
Are you taking medication for your concussion?
*
Are you taking medication for your concussion?
Yes
No
Medication Name
*
Medication Name
How Long have you taken this medication?
*
How Long have you taken this medication?
How often do you take this medication?
*
How often do you take this medication?
Less than once per week
Once per week
1-2 days per week
Most days per week
Daily
Multiple times daily
Is there additional medication you are taking?
*
Is there additional medication you are taking?
Yes
No
Medication Name
*
Medication Name
How Long have you taken this medication?
*
How Long have you taken this medication?
How often do you take this medication?
*
How often do you take this medication?
Less than once per week
Once per week
1-2 days per week
Most days per week
Daily
Multiple times daily
Is there additional medication you are taking?
*
Is there additional medication you are taking?
Yes
No
Medication Name
*
Medication Name
How Long have you taken this medication?
*
How Long have you taken this medication?
How often do you take this medication?
*
How often do you take this medication?
Less than once per week
Once per week
1-2 days per week
Most days per week
Daily
Multiple times daily
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Concussion Survey