Post-Concussion & Vestibular Intake

Rate symptoms and answer open questions to help guide care. Scale: 0 = Never, 1 = Rarely, 2 = Sometimes, 3 = Often, 4 = Very Often.

1) Snapshot

Name

Today’s Date

Accident Date

Brief description of the accident

Current providers / treatments

A. Cognitive & Post-Concussion Symptoms (6 items)

Item	0 1 2 3 4

B. Vestibular & Balance (6 items)

Item	0 1 2 3 4

C. Visual & Sensory (5 items)

Item	0 1 2 3 4

D. Emotional / Psychological (5 items)

Item	0 1 2 3 4

E. Sleep & Physical (4 items)

Item	0 1 2 3 4

F. Daily Functioning & Coping (5 items)

Item	0 1 2 3 4

Activities most difficult since the accident

Strategies/treatments that helped

Situations you currently avoid

Top goals for recovery/adaptation

Educational intake tool; not a diagnosis. Please discuss results with your clinician.