Concussion Patient Form Patient Form — Concussion Patient Name: First Last DOB: MM slash DD slash YYYY Date MM slash DD slash YYYY Were you referred to our office? Yes No Whom may we thank for referring you?Please fill out name, location, & contact information of the referral source.Name of professional who referred you:Address of professional who referred you: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Country PhoneFaxEmail Do we have permission to communicate findings with referral source? Yes No When was your last injury?Explain how the injury happened:What part of your head was injured?Were you treated by any other professionals for this injury? Yes No Please explain:Was there a previous injury? Yes No when did it occur and how did it happen?Did you have a CAT Scan or an MRI? Yes No what were the results?Was there a neurologic consult? Yes No Was there a medical consult? Yes No Were you hospitalized: Yes No for how long?Did you experience any loss of consciousness? Yes No Are you experiencing any dizziness? Yes No FrequencyDo you know what causes them?Are you experiencing any headaches? Yes No FrequencyDoes anything seem to cause them?What area of the head gets headaches?Please rate your headache level 1 to 10Nausea? Yes No Ringing in the ears? Yes No Balance problems? Yes No Double Vision? Yes No Blurry vision? Yes No Reading:Can you read comfortably Yes No For how long?Do you experience loss of place, skipping words, words moving on the page? Yes No Do you currently experience headaches, nausea, dizziness, blurry vision, or loss of place while reading? Yes No How long can you read before getting symptoms?How long does it take to recover from symptoms?Is it worse on paper or on an electronic screen?Please explain:Motion Sensitivity:Do you experience any of the following symptoms? Check all that apply. Disorientation Dizziness Nausea Headaches in Malls, Grocery Stores? Restaurants, Airports Classroom Hallways Crowds Other If you checked any of the above symptoms, where do you experience those symptoms? Check all that apply. Stores Malls Restaurants Airports Hallways Crowds Classroom Other Light Sensitivity:Are you sensitive to light indoors? Yes No Are you sensitive to light outdoors? Yes No Are you sensitive to fluorescent lighting? Yes No Carsickness:Did you experience carsickness after the injury? Yes No Do you experience carsickness when you are the driver? Yes No How long of a drive in the car before you experience the carsickness?Do you experience carsickness when you are the passenger? Yes No FOR STUDENTSDo you have any accommodations at school? Yes No What are they?FOR THOSE WHO ARE EMPLOYEDDo you have any accommodations in your work environment? Yes No What are they?PHYSICAL ACTIVITY:Are you restricted in your physical activities? Yes No In what way?REHABILITATION THERAPY:What rehabilitation therapy have you had?Name of Provider/FacilityWhat are the names and specialties of providers following/managing your care? Add RemoveList of Medications/vitamins you are taking Add RemoveHow often: Add RemoveNAME, TOWN AND PHONE NUMBER OF THE FOLLOWING PROVIDERS IF APPLICABLE: Name of the PRIMARY CARE DOCTOR: First Last PhoneTOWNName of the PSYCHOLOGIST: First Last PhoneTOWNName of the SPORTS DOCTOR: First Last PhoneTOWNName of the PHYSIATRIST: First Last PhoneTOWNName of the NEUROLOGIST: First Last PhoneTOWN Δ
