Complete Questionnaires Welcome to your Complete Questionnaires On Page 1 you will fill out the Post-Concussion Symptom Scale. On Page 2 you will fill out your activity score from the Post-Concussion Symptom Scale. --------------- I will ask you to complete this questionnaire before each physical therapy visit to track progress. These scales were adapted from Lovell and Collins, Journal of Head Trauma and Rehabilitation. 1998;13-9-26. --------------- On Page 3 you will fill out the Brain Injury Vision Symptom Survey. I will only ask you to do this survey on your first and final physical therapy visit to track overall progress. -------------- On Page 4 you will fill out the Dizziness Handicap Inventory (DHI) - please fill this out only for symptoms of dizziness! I will only ask you to do this survey on your first and final physical therapy visit to track overall progress. -------------- I know it is a lot of paperwork and so appreciate your taking the time to complete these outcome measures! 1. Headache 0 1 2 3 4 5 6 None 2. Nausea 0 1 2 3 4 5 6 None 3. Vomiting 0 1 2 3 4 5 6 None 4. Balance Problems 0 1 2 3 4 5 6 None 5. Dizziness 0 1 2 3 4 5 6 None 6. Visual Problems 0 1 2 3 4 5 6 None 7. Fatigue 0 1 2 3 4 5 6 None 8. Sensitivity to Light 0 1 2 3 4 5 6 None 9. Sensitivity to Noise 0 1 2 3 4 5 6 None 10. Numbness/Tingling 0 1 2 3 4 5 6 None 11. Feeling Mentally Foggy 0 1 2 3 4 5 6 None 12. Feeling Slowed Down 0 1 2 3 4 5 6 None 13. Difficulty Concentrating 0 1 2 3 4 5 6 None 14. Difficulty Remembering 0 1 2 3 4 5 6 None 15. Drowsiness 0 1 2 3 4 5 6 None 16. Sleeping Less than Usual 0 1 2 3 4 5 6 None 17. Sleeping More than Usual 0 1 2 3 4 5 6 None 18. Trouble Falling Asleep 0 1 2 3 4 5 6 None 19. Irritability 0 1 2 3 4 5 6 None 20. Sadness 0 1 2 3 4 5 6 None 21. Nervousness 0 1 2 3 4 5 6 None 22. Feeling More Emotional 0 1 2 3 4 5 6 None 23. Pain other than Headache 0 1 2 3 4 5 6 None 1 out of 4 24. Do these symptoms worsen with Physical Activity? Yes No Not Applicable None 25. Do these symptoms worsen with Thinking/Cognitive Activity? Yes No Not Applicable None 26. Over the PAST 2 DAYS, my daily activity has been ____% of normal 2 out of 4 27. Distance vision blurred and not clear - even with lenses This page includes all the questions from the Brain Injury Vision Symptom Survey Never Seldom Occassionally Frequently Always None 28. Near vision blurred and not clear - even with lenses Never Seldom Occassionally Frequently Always None 29. Clarity of vision changes or fluctuates during the day Never Seldom Occassionally Frequently Always None 30. Poor night vision / can't see well to drive at night Never Seldom Occassionally Frequently Always None 31. Eye discomfort / sore eyes / eye strain Never Seldom Occassionally Frequently Always None 32. Headaches or dizziness after using eyes Never Seldom Occassionally Frequently Always None 33. Eye fatigue / very tired after using eyes all day Never Seldom Occassionally Frequently Always None 34. Feel "pulling" around the eyes Never Seldom Occassionally Frequently Always None 35. Double vision - especially when tired Never Seldom Occassionally Frequently Always None 36. Have to close or cover one eye to see clearly Never Seldom Occassionally Frequently Always None 37. Print moves in and out of focus when reading Never Seldom Occassionally Frequently Always None 38. Normal indoor lighting is uncomfortable - too much glare Never Seldom Occassionally Frequently Always None 39. Outdoor light too bright - have to use sunglasses Never Seldom Occassionally Frequently Always None 40. Indoors fluorescent lighting is bothersome or annoying Never Seldom Occassionally Frequently Always None 41. Eyes feel "dry" and sting Never Seldom Occassionally Frequently Always None 42. "Stare" into space without blinking Never Seldom Occassionally Frequently Always None 43. Have to rub the eyes a lot Never Seldom Occassionally Frequently Always None 44. Clumsiness / misjudge where objects really are Never Seldom Occassionally Frequently Always None 45. Lack of confidence walking / missing steps / stumbling Never Seldom Occassionally Frequently Always None 46. Poor handwriting (spacing, size, legibility) Never Seldom Occassionally Frequently Always None 47. Side vision (peripheral vision) distorted / objects move or change position Never Seldom Occassionally Frequently Always None 48. What looks straight ahead isn't always straight ahead Never Seldom Occassionally Frequently Always None 49. Avoid crowds / can't tolerate "visually-busy" places Never Seldom Occassionally Frequently Always None 50. Short attention span / easily distracted when reading Never Seldom Occassionally Frequently Always None 51. Difficulty / slowness with reading and writing Never Seldom Occassionally Frequently Always None 52. Poor reading comprehension / can't remember what was read Never Seldom Occassionally Frequently Always None 53. Confusion of words / skip words during reading Never Seldom Occassionally Frequently Always None 54. Lose place / have to use finger not to lose place when reading Never Seldom Occassionally Frequently Always None 3 out of 4 55. Does looking up increase your problem? This page includes all questions from the Dizziness Handicap Index - please only complete these questions based on your DIZZINESS No Sometimes Yes None 56. Because of your problem, do you feel frustrated? No Sometimes Yes None 57. Because of your problem, do you restrict your travel for business or recreation? No Sometimes Yes None 58. Does walking down the aisle of a supermarket increase your problem? No Sometimes Yes None 59. Because of your problem, do you have difficulty getting into or out of bed? No Sometimes Yes None 60. Does your problem significantly restrict your participation in social activities such as going out to dinner, going to the movies, dancing, or to parties? No Sometimes Yes None 61. Because of your problem, do you have difficulty reading? No Sometimes Yes None 62. Does performing more ambitious activities such as sports, dancing, household chores (sweeping or putting dishes away) increase your problems? No Sometimes Yes None 63. Because of your problem, are you afraid to leave your home without someone accompanying you? No Sometimes Yes None 64. Because of your problem, have you been embarrassed in front of others? No Sometimes Yes None 65. Do quick movements of your head increase your problem? No Sometimes Yes None 66. Because of your problem, do you avoid heights? No Sometimes Yes None 67. Does turning over in bed increase your problem? No Sometimes Yes None 68. Because of your problem, is it difficult for you to do strenuous housework or yard work? No Sometimes Yes None 69. Because of your problem, are you afraid people may think you are intoxicated? No Sometimes Yes None 70. Because of your problem, is it difficult for you to walk by yourself? No Sometimes Yes None 71. Does walking down a sidewalk increase your problem? No Sometimes Yes None 72. Because of your problem, is it difficult for you to concentrate? No Sometimes Yes None 73. Because of your problem, is it difficult for you to walk around your house in the dark? No Sometimes Yes None 74. Because of your problem, are you afraid to stay home alone? No Sometimes Yes None 75. Because of your problem, do you feel handicapped? No Sometimes Yes None 76. Has your problem placed stress on your relationships with members of your family or friends? No Sometimes Yes None 77. Because of your problem, are you depressed? No Sometimes Yes None 78. Does your problem interfere with your job or household responsibilities? No Sometimes Yes None 79. Does bending over increase your problem? No Sometimes Yes None 4 out of 4 Time's up September 15, 2022/0 Comments/by Steve Whitesell https://phoenixconcussionrecovery.com/wp-content/uploads/2017/06/Phoenix_Logo.png 0 0 Steve Whitesell https://phoenixconcussionrecovery.com/wp-content/uploads/2017/06/Phoenix_Logo.png Steve Whitesell2022-09-15 11:01:562022-09-15 11:01:56Complete Questionnaires
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