Concussion Subtype Questionnaire

Name

First NameLast Name

Email

example@example.com

Mobile Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Were you diagnosed with a concussion in the past 6 months?

Do you suspect you might have sustained a concussion in the past 6 months?

Below are a list of symptoms that people might experience. Please read each symptom and select the option that best represents the severity of each symptom over the past 7 days. You must provide a response to each symptom.

Rows	None	Mild	Moderate	Severe	Critical
Feeling Frustrated or Impatient
Anxious
Sadness
Irritability
More Emotional
Restlessness
Sweats/Chills
Hot/Cold Extremities
Pressure in Head
Feel Worse After Physical Exertion
Nausea
Light Headed/ Uncomfortable Standing
Bladder Discomfort/Changes
Irregular/Rapid Heart Rate
Trouble With Memory
Difficulty Concentrating
Slower Speed of Thinking
Confusion
Trouble Word Finding
Shortness of Breath
Feeling Feverish
Feeling in a Fog
Don't Feel Right
Fatigue/Low Energy
Trouble Falling or Staying Asleep
Not Feeling Rested
Sleeping Too Much
Needing More Sleep
Muscle Weakness
Numbness or Tingling
Sensitivity to Noise
Back Pain
Joint Pain/Swelling
Headaches
Muscle Pain/Aches
Shooting, Stabbing, Burning Pain
Skin/Muscle Twitching
Balance Problem
Neck Pain (Stiffness)
Dizziness
Sensitivity to Light
Blurry/Double Vision
Difficulty With Moving Scenery
Motion Intolerance
Visual Disturbance (Snow, Spots)
Eye Strain

Upon selecting submit, your score will be calculated, and an email containing an interpretation of the score will be sent to the email you provided.

Total Symptom Severity (0-100)

Affect Cluster %

Autonomic Cluster %

Cognitive Cluster %

Inflammation Cluster %

Sleep Cluster %

Somatic Cluster %

Vestibular Cluster %

Visual Cluster %

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