Test Concussion Vector Questionnaire INSTRUCTIONS: Please check the most appropriate circle for each field. Please rate each symptom Headache None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Nausea None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Vomiting None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Balance Problems None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Dizziness (spinning or movement sensation) None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Lightheadedness None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Fatigue None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Trouble falling asleep None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Sleeping more than usual None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Sleeping less than usual None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Drowsiness None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Sensitivity to light None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Sensitivity to noise None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Irritability None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Sadness / Hopelessness None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Nervous / Anxious None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Feeling more emotional None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Numbness or tingling None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Feeling slowed down None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Feeling like "in a fog" None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Difficulty concentrating None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Difficulty remembering None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Visual problems None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Slow wavy dizziness None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Ruminating thoughts None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Difficulty in Math, Science, Reading None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Symptoms worse at the end of day None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Difficulty with attention None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Difficulty finding words None Mild Moderate Severe Vision Vestibular Migraine Cognitive Cervical Anxiety Send
