PCSS All Visits Welcome to your PCSS All Visits 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. ----------------- This questionnaire will take approximately 2-4minutes and is important for measuring your progress! Name Email Today's Date 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 2 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 2 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 11:01:322022-09-15 11:01:32PCSS All Visits
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