PCSS

Post Concussion Symptom Scale

Question Title

* 1. Please type your name. Surname, First Name

Question Title

* 2. PHYSICAL SYMPTOMS

Since the Injury, have you experienced any of the following symptoms, any more than usual, today or in the past day? Please choose a level for each symptom.

	0 none	1	2	3	4	5	6 severe
Headache	Headache 0 none	Headache 1	Headache 2	Headache 3	Headache 4	Headache 5	Headache 6 severe
Nausea	Nausea 0 none	Nausea 1	Nausea 2	Nausea 3	Nausea 4	Nausea 5	Nausea 6 severe
Vomiting	Vomiting 0 none	Vomiting 1	Vomiting 2	Vomiting 3	Vomiting 4	Vomiting 5	Vomiting 6 severe
Balance Problems	Balance Problems 0 none	Balance Problems 1	Balance Problems 2	Balance Problems 3	Balance Problems 4	Balance Problems 5	Balance Problems 6 severe
Dizziness	Dizziness 0 none	Dizziness 1	Dizziness 2	Dizziness 3	Dizziness 4	Dizziness 5	Dizziness 6 severe
Lightheadedness	Lightheadedness 0 none	Lightheadedness 1	Lightheadedness 2	Lightheadedness 3	Lightheadedness 4	Lightheadedness 5	Lightheadedness 6 severe
Fatigue	Fatigue 0 none	Fatigue 1	Fatigue 2	Fatigue 3	Fatigue 4	Fatigue 5	Fatigue 6 severe
Trouble falling asleep	Trouble falling asleep 0 none	Trouble falling asleep 1	Trouble falling asleep 2	Trouble falling asleep 3	Trouble falling asleep 4	Trouble falling asleep 5	Trouble falling asleep 6 severe
Sleeping more than usual	Sleeping more than usual 0 none	Sleeping more than usual 1	Sleeping more than usual 2	Sleeping more than usual 3	Sleeping more than usual 4	Sleeping more than usual 5	Sleeping more than usual 6 severe
Sleeping less than normal	Sleeping less than normal 0 none	Sleeping less than normal 1	Sleeping less than normal 2	Sleeping less than normal 3	Sleeping less than normal 4	Sleeping less than normal 5	Sleeping less than normal 6 severe
Drowsiness	Drowsiness 0 none	Drowsiness 1	Drowsiness 2	Drowsiness 3	Drowsiness 4	Drowsiness 5	Drowsiness 6 severe
Sensitivity to light	Sensitivity to light 0 none	Sensitivity to light 1	Sensitivity to light 2	Sensitivity to light 3	Sensitivity to light 4	Sensitivity to light 5	Sensitivity to light 6 severe
Sensitivity to noise	Sensitivity to noise 0 none	Sensitivity to noise 1	Sensitivity to noise 2	Sensitivity to noise 3	Sensitivity to noise 4	Sensitivity to noise 5	Sensitivity to noise 6 severe
Irritability	Irritability 0 none	Irritability 1	Irritability 2	Irritability 3	Irritability 4	Irritability 5	Irritability 6 severe
Sadness	Sadness 0 none	Sadness 1	Sadness 2	Sadness 3	Sadness 4	Sadness 5	Sadness 6 severe
Nervous/Anxious	Nervous/Anxious 0 none	Nervous/Anxious 1	Nervous/Anxious 2	Nervous/Anxious 3	Nervous/Anxious 4	Nervous/Anxious 5	Nervous/Anxious 6 severe
Feeling more emotional	Feeling more emotional 0 none	Feeling more emotional 1	Feeling more emotional 2	Feeling more emotional 3	Feeling more emotional 4	Feeling more emotional 5	Feeling more emotional 6 severe
Numbness/Tingling	Numbness/Tingling 0 none	Numbness/Tingling 1	Numbness/Tingling 2	Numbness/Tingling 3	Numbness/Tingling 4	Numbness/Tingling 5	Numbness/Tingling 6 severe
Feeling slowed down	Feeling slowed down 0 none	Feeling slowed down 1	Feeling slowed down 2	Feeling slowed down 3	Feeling slowed down 4	Feeling slowed down 5	Feeling slowed down 6 severe
Feeling like "in a fog"	Feeling like "in a fog" 0 none	Feeling like "in a fog" 1	Feeling like "in a fog" 2	Feeling like "in a fog" 3	Feeling like "in a fog" 4	Feeling like "in a fog" 5	Feeling like "in a fog" 6 severe
Difficulty concentrating	Difficulty concentrating 0 none	Difficulty concentrating 1	Difficulty concentrating 2	Difficulty concentrating 3	Difficulty concentrating 4	Difficulty concentrating 5	Difficulty concentrating 6 severe
Difficulty remembering	Difficulty remembering 0 none	Difficulty remembering 1	Difficulty remembering 2	Difficulty remembering 3	Difficulty remembering 4	Difficulty remembering 5	Difficulty remembering 6 severe
Visual problems	Visual problems 0 none	Visual problems 1	Visual problems 2	Visual problems 3	Visual problems 4	Visual problems 5	Visual problems 6 severe

Question Title

* 1. Please type your name. Surname, First Name

Question Title

* 2. PHYSICAL SYMPTOMSSince the Injury, have you experienced any of the following symptoms, any more than usual, today or in the past day? Please choose a level for each symptom.

Question Title

* 3. Interpretation of scores (for office use only)TOTAL SCORE: add up the total scores = _______/1320(min symptoms)-132(max symptoms)

* 2. PHYSICAL SYMPTOMS

Since the Injury, have you experienced any of the following symptoms, any more than usual, today or in the past day? Please choose a level for each symptom.

* 3. Interpretation of scores (for office use only)

TOTAL SCORE: add up the total scores = _______/132
0(min symptoms)-132(max symptoms)