| Primary Insurance | |
| Insurance Name | Value |
| Member Name | Value |
| Policy Number | Value |
| Certificate Number | Value |
| Date Of Birth | Value |
| Relationship to the patient | Value |
| Secondary Insurance | |
| Insurance Name | Value |
| Member Name | Value |
| Policy Number | Value |
| Certificate Number | Value |
| Date Of Birth | Value |
| Relationship to the patient | Value |
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INSURANCE INFORMATION
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The Rivermead Post-Concussion Symptoms Questionnaire*
| After a head injury or accident some people experience symptoms which can cause worry or nuisance. We would like to know if you now suffer from any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one, please click the number closest to your answer. | |||||
| Symptom | 0 | 1 | 2 | 3 | 4 |
|---|---|---|---|---|---|
| Headaches | |||||
| Feelings of Dizziness | |||||
| Nausea and/or Vomiting | |||||
| Noise Sensitivity easily upset by loud noise | |||||
| Sleep Disturbance | |||||
| Fatigue, tiring more easily | |||||
| Being Irritable, easily angered | |||||
| Feeling Depressed or Tearful | |||||
| Feeling Frustrated or Impatient | |||||
| Forgetfulness, poor memory | |||||
| Poor Concentration | |||||
| Taking Longer to Think | |||||
| Blurred Vision | |||||
| Light Sensitivity | |||||
| Double Vision Easily upset by bright light | |||||
| Restlessness | |||||
| Are you experiencing any other difficulties? | |||||
| Initial Concussion Patient Interview | |
| Patient Name | Value |
| Date of Injury | Value |
| Date of Assessment | Value |
| Referral Signs |
|
| Mechanism of Injury Direct Head Contact InDirect(whiplash) |
Value |
| Early Symptoms Experienced: | Value |
| Relevant Medical Follow Ups, Specialists /Evaluations | Value |
| Imaging, Special Testing, New Medications | Value |
| Occupation at time of Injury | Value |
| Current Work/Academic Load |
|
| Current/Ongoing Symptoms and Functional Limitations |
|
| Notes/other | Value |
| History of Concussion or Head/Neck Traum | Value |
| Relevant Medical History (Cardio/Neuro/Metabolic/Respiratory) | Value |
Health History Screening Questions
| Headache/Migraine History Pre-Concussion | Yes If Yes. |
| Headache/Migraine History Pre-Concussion | No |
| Pre-Injury Anxiety/Depression? | Yes If Yes. |
| Hx of Learning Disability? | No |
| Any Known Vestibular Hx? | No |
| Hx Motion Sickness? | No |
| Additional Notes | Value |
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Clinical Evaluation P1
| CRANIAL NERVE SCREEN | Clear | Abn. |
|---|---|---|
| CN I (olfactory) | ||
| CN II (visual fields,pupiIlary reflex) | ||
| CN III(H Pattern) | ||
| CN IV(SO - lat/inf) | ||
| CN V(Sensory/mastication mm) | ||
| CN VI(LR-lat) | ||
| CN VII(facial expression mm) | ||
| CNVIII (nystag, whisper) | ||
| CN IX(taste/posteriortongue) | ||
| CN X(uvula, swallow, vocal cords) | ||
| CN IX(Trap,SCM) | ||
| CN IX(tongue mm, articulation) |
| GROSS NEUROVASCULAR | |
| Cerebellar Signs? | Yes |
| UMN Signs? | No |
| Sensory Changes? | Yes |
| Myotome Weakness? | No |
| DTRs | Value |
| Vast | Neg |
| 5D's, 3N's(list) | Value |
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Vestibular & Oculomotor Screen
| Gaze Fixation | ||
| NPC |
Break 1
Break 2 Break 3 |
|
| Accommodation | ||
| Pursuits | ||
| Saccades | ||
| VOR (180 bpm) | ||
| VMS (50 bpm) |
Clinical Evaluation P2 - Special Testing (If Indicated)
| Head Thrust Test | ||
| Dynamic Visual Acuity | Value | |
| Dix Hallpike | Value | |
| Lateral Pos/Head Roll | Value | |
| Visual Fields (confrontation) |
Value |
|
| Other |
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