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Rivermead

Rivermead Post-Concussion Symptoms Questionnaire.

Every question is on this page. The date is filled with today.

Your information

Name * Date *

Symptoms compared with before the accident

Headaches *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Feelings of dizziness *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Nausea and/or vomiting *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Noise sensitivity, easily upset by loud noise *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Sleep disturbance *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Fatigue, tiring more easily *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Being irritable, easily angered *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Feeling depressed or tearful *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Feeling frustrated or impatient *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Forgetfulness, poor memory *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Poor concentration *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Taking longer to think *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Blurred vision *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Light sensitivity, easily upset by bright light *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Double vision *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Symptoms compared with before the accident

Restlessness *

0 Not experienced at all 1 No more of a problem 2 Mild problem 3 Moderate problem 4 Severe problem

Anderson Physical Therapy

Your Tri-Cities physical therapy clinics in Kennewick, Pasco, and Sunnyside. Compassionate care for car accidents, work injuries, sports, and everyday pain.

(509) 735-3555 Kennewick (509) 735-3555 Pasco (509) 839-0414 Sunnyside

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Kennewick
512 Young Street, Suite C
Kennewick, WA 99336
(509) 735-3555
Pasco
3603 W Court St
Pasco, WA 99301
(509) 735-3555
Sunnyside
841 E Lincoln Ave
Sunnyside, WA 98944
(509) 839-0414

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