Concussion / PCS Symptom Severity Score Form

Concussion / PCS Symptom Severity Score
Patient Name*

First NameLast Name
Date of Injury*

MonthDayYear
Date
Purpose: A concussion is a mild traumatic brain injury (MTBI) that may cause a range of physical and cognitive symptoms. The Concussion Symptom Severity Score is essentially a "current state" measure of the patient's concussive symptoms. The patient is asked to report the "current" experience of symptoms on a scale of 0-6. There are 22 symptoms overall with a possible total score of 132. The scoring allows tracking of symptoms during treatment intervals. The Concussion Symptom Severity Score can be utilized as an outcome measure to demonstrate improvement or lack of improvement.
Outcome Measures

Symptom Severity Score*

Concussion / PCS Symptom Severity Score