Please answer Yes or No and/or explain where applicable. In your opinion, has the general condition of your health improved?* Which symptoms have improved?
Can you now engage in activities which were prohibited or limited by your previous condition?* Which activities?
Have you been careful to avoid bumps, falls, and sudden shock that might re-injure your: spine, shoulder, elbow, wrist, hip, knee or feet, during the period required for re-adaptation?* Have you followed the recommendations of this office regarding posture changes at work, sleep, rest, icing and stretching?* Has there been any recurrence of symptoms you experienced prior to becoming a patient of this office?* Please explain your recurring symptoms.*
Are the symptoms different in any way to those previously experienced?
Are you being treated for a concussion/s?* No Yes
Are you experiencing any of the following cognitive symptoms of a concussion?* Please check all that apply.
Has the symptom "difficulty thinking clearly"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "difficulty concentrating"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "difficulty remembering new information"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "disorientation"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "temporary amnesia"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "short-term memory problems"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "poor judgement"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "slow thinking"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "difficulty reading"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "difficulty with math"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "poor word recall"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "forgetting people's names"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "poor decision making"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "lack of organization"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "longer response time"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "confusion"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "brain fog"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "forgetting previously learned skills"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "difficulty driving"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "get lost easily"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "spelling difficulty"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "poor comprehension"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "difficulty following instructions"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "difficult to think in noisy environments"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "inability to multitask"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "poor follow through"...* Improved Stayed the same Gotten Worse N/A
Has this symptom "difficulty with logic"...* Improved Stayed the same Gotten Worse N/A
Has this symptom "difficulty with abstract thinking and being creative"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "difficult to watch TV, use the computer or play video games"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "loss of consciousness"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "slurred speech"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "absence speech"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "chills"...* Improved Stayed the same Gotten Worse N/A
Has the symptom "difficulty staying focused"...* Improved Stayed the same Gotten Worse N/A
Are you experiencing any of the following physical symptoms of a concussion?* Please select all that apply.
Has the symptom "headache"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "migraine"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "tension headaches"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "fuzzy or blurry vision"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "double vision"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "feeling groggy"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "nausea and vomiting"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "dizziness or lightheadedness"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "sensitivity to noise, light or touch"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "balance problems"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "fatigue"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "feeling tired"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "having no energy"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "TMJ issues"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "hearing problems"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "tinnitus"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "loss of libido"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "exaggerated awareness of aches and pains"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "loss of balance"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "sense or smell or taste change"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "difficulty swallowing"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "slowed reflexes"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "gait changes"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "co-ordination or speed of performance"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "seizures"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "pressure in the head"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "neck pain"...* Impoved Stayed the same Gotten worse N/A
Has this symptom "strange taste in mouth"...* Impoved Stayed the same Gotten worse N/A
Has the symptom "seeing stars"...* Impoved Stayed the same Gotten worse N/A
Are you experiencing any of the following sleep related symptoms of a concussion?* Please select all that apply.
Has the symptom "sleeping more than usual"...* Improved Stayed the same Gotten worse N/A
Has the symptom "sleeping less than usual"...* Improved Stayed the same Gotten worse N/A
Has the symptom "trouble falling or staying asleep"...* Improved Stayed the same Gotten worse N/A
Are you experiencing any of the following mood/emotional symptoms of a concussion?* Has the symptom "irritability"...* Improved Stayed the same Gotten worse N/A
Has the symptom "sadness"...* Improved Stayed the same Gotten worse N/A
Has the symptom "more emotional"...* Improved Stayed the same Gotten worse N/A
Has the symptom "nervousness or anxiety"...* Improved Stayed the same Gotten worse N/A
Has the symptom "depressed"...* Improved Stayed the same Gotten worse N/A
Has the symptom "agitation"...* Improved Stayed the same Gotten worse N/A
Has the symptom "apathy"...* Improved Stayed the same Gotten worse N/A
Has this symptom "anxiety"...* Improved Stayed the same Gotten worse N/A
Has the symptom "feeling of going crazy"...* Improved Stayed the same Gotten worse N/A
Has the symptom "frustration"...* Improved Stayed the same Gotten worse N/A
Has the symptom "anger"...* Improved Stayed the same Gotten worse N/A
Has the symptom "hostility"...* Improved Stayed the same Gotten worse N/A
Has the symptom "paranoia"...* Improved Stayed the same Gotten worse N/A
Has the symptom "guilt"...* Improved Stayed the same Gotten worse N/A
Has the symptom "shame"...* Improved Stayed the same Gotten worse N/A
Has the symptom "helplessness"...* Improved Stayed the same Gotten worse N/A
Has the symptom "why me"...* Improved Stayed the same Gotten worse N/A
Has the symptom "mood swings"...* Improved Stayed the same Gotten worse N/A
Has the symptom "low motivation"...* Improved Stayed the same Gotten worse N/A
Has the symptom "gullibility"...* Improved Stayed the same Gotten worse N/A
Has the symptom "easily overwhelmed"...* Improved Stayed the same Gotten worse N/A
Has this symptom "exaggerated response to stimuli"...* Improved Stayed the same Gotten worse N/A
Has the symptom "low self-esteem"...* Improved Stayed the same Gotten worse N/A
Has the symptom "nightmares"...* Improved Stayed the same Gotten worse N/A
Has the symptom "day terrors"...* Improved Stayed the same Gotten worse N/A
Has the symptom "mania"...* Improved Stayed the same Gotten worse N/A
Has the symptom "excessive excitement"...* Improved Stayed the same Gotten worse N/A
Are you experiencing any of the following behavioural symptoms of a concussion?* Please select all that apply.
Has the symptom "confrontational"...* Improved Stayed the same Gotten worse N/A
Has the symptom "temper tantrums"...* Improved Stayed the same Gotten worse N/A
Has the symptom "fearfulness"...* Improved Stayed the same Gotten worse N/A
Has the symptom "impatience"...* Improved Stayed the same Gotten worse N/A
Has the symptom "thoughtlessness"...* Improved Stayed the same Gotten worse N/A
Has the symptom "compulsive behaviours"...* Improved Stayed the same Gotten worse N/A
Has the symptom "obsessive behaviours"...* Improved Stayed the same Gotten worse N/A
Has the symptom "lack of social ease"...* Improved Stayed the same Gotten worse N/A
Has the symptom "personality changes"...* Improved Stayed the same Gotten worse N/A
Has the symptom "Bi-polar"...* Improved Stayed the same Gotten worse N/A
Has the symptom "difficulty adapting to change"...* Improved Stayed the same Gotten worse N/A