Concussion Clinical Profiles Screening (CP Screen)

Test

Concussion Clinical Profiles Screening (CP Screen)

INSTRUCTIONS: Please click the appropriate response from the dropdown menu under each question

Please rate each symptom

Feeling Sad

Headache when you wake up

Difficulty or headache when looking at a phone or computer

Dizziness when you move your head

Difficulty turning off your thoughts (eg. rumination)

Headache with nausea or upset stomach

Trouble focusing your eyes while reading

Frontal headache

Difficulty or discomfort in busy environments

Constantly thinking about your symptoms

Headache with sensitivity to light or noise

Feeling motion sick ("Sea or car sick")

Feeling more tired at the end of the day

Blurry or double vision

Feeling sensation of slow wavy dizziness (e.g. Lightheadedness)

Neck pain or stiffness

Sleeping more than usual

Sleeping less than usual

Eye Strain (eyes feel tired) during visual activities

Visual Aura (e.g. flashes, stars, spots, flickering light) with or without headache

Feeling or sensation of fast spinning dizziness (e.g. vertigo)

Difficulty falling asleep

Difficulty staying asleep

Trouble remembering things (e.g. what you completed today or having to re-read information)

Difficulty moving your neck

Feeling nervous or anxious

Increased headache following physical activity

Increased headache following cognitive activity

Feeling more stressed than usual

Test

Concussion Clinical Profiles Screening (CP Screen)

Please rate each symptom

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