Post Concussion Questionnaire

We appreciate your time is valuable. Please be advised the questions in this survey are not compulsory however, they can provide your health professional with helpful information, which will assist them with best practice assessment/treatment following your head knock/concussion. Should you be experiencing difficulties completing this survey please arrive 15 minutes early to your next scheduled appointment and one of our friendly Engage VR staff members can assist you

Full name(Required)

First Name Last Name

Today's Date

Symptom Evaluation - Rivermead Post Concussion Symptom Questionnaire (RPQ)

Please rate your symptoms

	Not Experienced	Minimal Problem	Mild Problem	Moderate Problem	Severe Problem
Headaches
Feeling of Dizziness
Nausea or Vomiting
Noise Sensitivity
Sleep Disturbance
Fatigue, Tiring Easily
Irritable
Depressed or Tearful
Frustrated or Impatient
Forgetfulness, Poor Memory
Poor Concentration
Taking longer to think
Blurred Vision
Light sensitivity (Easily Upset by Bright Light)
Double Vision
Restlessness
Any other difficulties (please specify & score)

Other difficulties - Please specify

Do any of your symptoms rated above get worse with Physical Activity? (please tick all relevant)

Other difficulties - Please specify

Do any of your symptoms rated above get worse with Mental Activity? (please tick all relevant)

Other difficulties - Please specify

If 100% is feeling normal, what percent of normal do you feel right now?

If not 100%, why?

Generalised Anxiety Disorder (GAD-7)

Over the past 2 weeks, how often have you been bothered by any of the following problems?

	Not at all	Several Days	More then Half of the Days	Nearly Everyday
Feeling Nervous
Not being able to stop or control Worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid, as if something awful might happen

Patient Health Questionnaire (PHQ-8)

Over the past 2 weeks, how often have you been bothered by any of the following problems?

	Not at all	Several Days	More then Half of the Days	Nearly Everyday
Little interest or pleasure in doing things
Feeling Down, depressed, irritable or hopeless
Trouble falling or staying asleep or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things such as schoolwork, reading or watching television
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

Abbreviated Athlete Sleep Screening Questionnaire

During the past week how many hours of actual sleep did you get at night? (This may be different than the number of hours spent in bed)

How satisfied/dissatisfied were you with the quality of your sleep?

During the recent past, how long has it usually taken you to fall asleep each night?

How often do you have trouble staying asleep?

During the recent past, how often have you taken medicine to help you sleep? (prescribed or over the counter)

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Post Concussion Questionnaire