Pittsford Performance CareNeurologic Rehabilitation

Self-Assessment Tool

Concussion Self-Assessment

This questionnaire uses the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) to help assess your current symptoms.

Progress: 0 / 16 questions0%

Instructions: Please rate each symptom compared to how you felt before your injury. Select the option that best describes how much of a problem each symptom has been over the past 24 hours.

1Headaches

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

2Feelings of dizziness

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

3Nausea and/or vomiting

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

4Noise sensitivity

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

5Sleep disturbance

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

6Fatigue, tiring more easily

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

7Being irritable, easily angered

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

8Feeling depressed or tearful

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

9Feeling frustrated or impatient

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

10Forgetfulness, poor memory

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

11Poor concentration

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

12Taking longer to think

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

13Blurred vision

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

14Light sensitivity

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

15Double vision

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

16Restlessness

Not experienced at all

No more of a problem

A mild problem

A moderate problem

A severe problem

Please answer all questions to see your results