Full Circle Concussion Grading Mental Health Symptoms Scale
The Post Concussion Symptom Scale is essentially a “state” measure of perceived symptoms associated with concussion. That is, the athlete is asked to report his or her “current” experience of symptoms. This allows tracing of symptoms over very short intervals, such as consecutive days or every few days. Directions: After reading each symptom, please circle the number that best describes the way the athlete has been feeling today. A rating of 0 means they have not experienced this symptoms today. A rating of 6 means they have experienced severe problems with this symptom today.
Patient Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Fatigue
*
None
Mild 1
Mild 2
Moderate 3
Moderate 4
Severe 5
Severe 6
Trouble Falling Asleep
*
None
Mild 1
Mild 2
Moderate 3
Moderate 4
Severe 5
Severe 6
Sleeping More than Usual
*
None
Mild 1
Mild 2
Moderate 3
Moderate 4
Severe 5
Severe 6
Sleeping Less than Usual
*
None
Mild 1
Mild 2
Moderate 3
Moderate 4
Severe 5
Severe 6
Irritability
*
None
Mild 1
Mild 2
Moderate 3
Moderate 4
Severe 5
Severe 6
Sadness
*
None
Mild 1
Mild 2
Moderate 3
Moderate 4
Severe 5
Severe 6
Nervousness
*
None
Mild 1
Mild 2
Moderate 3
Moderate 4
Severe 5
Severe 6
Feeling More Emotional
*
None
Mild 1
Mild 2
Moderate 3
Moderate 4
Severe 5
Severe 6
Feeling Slowed Down
*
None
Mild 1
Mild 2
Moderate 3
Moderate 4
Severe 5
Severe 6
Feeling Mentally "Foggy"
*
None
Mild 1
Mild 2
Moderate 3
Moderate 4
Severe 5
Severe 6
Difficulty Concentrating
*
None
Mild 1
Mild 2
Moderate 3
Moderate 4
Severe 5
Severe 6
Difficulty Remembering
*
None
Mild 1
Mild 2
Moderate 3
Moderate 4
Severe 5
Severe 6
Total Symptom Score
Total Number of Symptom
*
ImPACT requires the subject to rate the severity of 12 concussive mental health related symptoms (e.g.) sadness, trouble falling asleep, nervousness, etc), via a 7-point Likert scale. Adapted from the Concussion Grading Scale
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