University of the Cumberlands
Symptomology Assessment Scale

 

NAME: SEX DATE
SPORT

EXAMINER
Have you ever been knocked out? Yes No
If “Yes” how many times?
Have you ever been diagnosed with a concussion? Yes No
If “Yes” how many times?
Have you been evaluated using X-ray / CT Scan / MRI or other for a past head injury? Yes No
If “Yes” please indicate the date (Month/Year):
System checklist: Choose “yes” if you routinely experience the symptom or “no” if you do not routinely experience the symptom.
headache Yes No headache brought on by exercise Yes No
nausea / upset stomach Yes No difficulty balancing /dizziness Yes No
fatigue / overly tired Yes No feeling like you are “in a fog” Yes No
sleep difficulty Yes No difficulty concentrating Yes No
drowsiness / Sleepiness Yes No feeling “slowed down” Yes No
appetite trouble Yes No blurred or double vision Yes No
sensitivity to light Yes No    

If you answered “Yes” to any of the above symptoms please go to the corresponding symptom below and using the outlined directions indicate your symptom experience.

Symptom Scale: For the duration side of the scale, circle the number that best describes how long you routinely experience each symptom. “1” indicates that you briefly experienced the symptom before it resolved. “6” indicates that the symptom has been a constant experience.. Once you finish reporting the duration, please respond to the severity scale by circling the number that best describes how severe the symptom has felt to you “1” indicates that the symptom felt mildly, “6” indicates the symptom was as severe as you could possibly imagine.

 

 
DURATION
SEVERITY
 
brief------------------------------constant
not severe -----------as severe as possible
Headache
1 2 3 4 5 6
1 2 3 4 5 6
Headache-Exercise Induced
1 2 3 4 5 6
1 2 3 4 5 6
Nausea / Upset Stomach
1 2 3 4 5 6
1 2 3 4 5 6
Difficulty balancing / dizziness
1 2 3 4 5 6
1 2 3 4 5 6
Fatigue / overly tired
1 2 3 4 5 6
1 2 3 4 5 6
Feeling “in a fog”
1 2 3 4 5 6
1 2 3 4 5 6
Sleep difficulty
1 2 3 4 5 6
1 2 3 4 5 6
Difficulty concentrating
1 2 3 4 5 6
1 2 3 4 5 6
Drowsiness / Sleepiness
1 2 3 4 5 6
1 2 3 4 5 6
Feeling “slowed down”
1 2 3 4 5 6
1 2 3 4 5 6
Loss of Appetite
1 2 3 4 5 6
1 2 3 4 5 6
Blurred or double vision
1 2 3 4 5 6
1 2 3 4 5 6
Sensitivity to light
1 2 3 4 5 6
1 2 3 4 5 6
  Duration Sum: Severity Sum:

Post concussion Assessment/ Re-exam will use the Baseline score as normal for the person being tested.