Authorization PDF Form

Symptom	0	1	2	3	4
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.
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	Worsening Headache Fluctuating Consciousness
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	Off work/school Full time/demands
Current/Ongoing Symptoms and Functional Limitations	Head Pressure Sleep Challenges
Notes/other	Value
History of Concussion or Head/Neck Traum	Value
Relevant Medical History (Cardio/Neuro/Metabolic/Respiratory)	Value

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

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)

Clin Impression	Value
Trajectories	Value
Referrals	Value
POM	Value
Tests to Perform	Value
Rehab to Initiate	Value
If Others	Value
Patient Aware Care to be shared w/ Kin and Consents?	Yes
Name	Value
Signature	Value
Date	Value
Relationship to the patient	Value

Gaze Fixation	Normal Abnormal	Poor Fixation (Sign) Symptoms
NPC	Normal NPC X3 < 6cm Abnormal / Remote NPC Abnormal Recovery > 3-4cm	Break 1 Break 2 Break 3 Symptoms
Accommodation	Normal Abnormal Amps (for age)
Pursuits	Normal Abnormal Horiz Abnormal Vert	Nystagmus Saccadic Movement Symptoms
Saccades	Normal Abnormal Horiz Abnormal Vert	Undershoot/Overshoot Difficult/Slow/Pauses Symptoms
VOR (180 bpm)	Normal Abnormal Horiz Abnormal Vert	Does not maintain fixation Unable to keep target in focus Symptoms
VMS (50 bpm)	Normal Abnormal	Does not maintain fixation Symptoms

Head Thrust Test	Normal Abn R Abn L
Dynamic Visual Acuity	Normal Abnormal (>=2 lines)	Value
Dix Hallpike	Normal Abnormal	Value
Lateral Pos/Head Roll	Normal Abnormal	Value
Visual Fields (confrontation)	Normal Reduced	Generalized Pattern Specific Value
Other	Normal Abnormal

Normal Gait	Normal Abnormal	Unstable/Abnormal Pattern Unilateral Drift R L
Tandem Gait (fwd, bkwd) Eyes open, 5 steps*	Normal Abnormal	Fall/Unstable/Overstep Unilateral Drift R L
Tandem Gait (fwd, bkwd) Eyes closed, 5 steps*	Normal Abnormal	Fall/Unstable/Overstep Unilateral Drift R L
Balance: Feet together (Firm) Eyes closed (20s)*	Normal Abnormal	Fall Out of Position Sway Symptoms (Dizzy)
Balance: Semi Tandem (Firm) Eyes closed (20s)*	Normal Abnormal	Fall Out of Position Sway Symptoms (Dizzy)
Balance: Feet Together (Foam) Eyes closed (20s)*	Normal Abnormal	Fall Out of Position Sway Symptoms (Dizzy)
Others	Normal Abnormal

Upper Cervical Ligs	Normal Abnormal
Range Of Motions Flexion(5d) Extension (60d) Right Lateral Flexion (40-45d) Left Lateral Flexion (40-45d) Right Rotation (80d) Left Rotation (80d)	Normal Reduced Normal Reduced Normal Reduced Normal Reduced Normal Reduced Normal Reduced
Joint Tenderness Upper Cervical (C1-3) Lower Cervical (C4-7)	Normal Pain/Restriction Normal Pain/Restriction
Myofascial Tone/Tenderness Suboccipital Other	Normal Pain/Restriction Normal Pain/Restriction
Special Testing (eg. C-Flex/Rot; Comp/Spurl/DNF/N.Torsion/Rotary stool):	Normal Abnormal