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Symptom Inventory Form

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Your Assessment Results

Total Symptom Score

0

out of 144 (0%)

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What This Means

Recommended Next Steps

Important: This assessment is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding your symptoms and treatment options.

Patient Information

First Name *

Last Name *

Email Address *

Phone Number

Overall Performance

If 100 is before your injury, where are you performing at now?

50

Symptom Triggers

Symptoms get worse with mental activity

None 1 2 3 4 5 6

Gets worse with Physical Activity

None 1 2 3 4 5 6

Physical Symptoms

Headache

None 1 2 3 4 5 6

Pressure in Head

None 1 2 3 4 5 6

Nausea or Vomiting

None 1 2 3 4 5 6

Neck Pain

None 1 2 3 4 5 6

Dizziness

None 1 2 3 4 5 6

Blurred Vision

None 1 2 3 4 5 6

Balance Problems

None 1 2 3 4 5 6

Sensitivity to Light

None 1 2 3 4 5 6

Sensitivity to Noise

None 1 2 3 4 5 6

Cognitive Symptoms

Feeling Slowed Down

None 1 2 3 4 5 6

“Don’t Feel Right”

None 1 2 3 4 5 6

Difficulty Concentrating

None 1 2 3 4 5 6

Difficulty Remembering

None 1 2 3 4 5 6

Fatigue or Low Energy

None 1 2 3 4 5 6

Confusion

None 1 2 3 4 5 6

Drowsiness

None 1 2 3 4 5 6

Feeling in a Fog

None 1 2 3 4 5 6

Emotional & Behavioral Symptoms

More Emotional

None 1 2 3 4 5 6

Sadness

None 1 2 3 4 5 6

Nervous

None 1 2 3 4 5 6

Irritability

None 1 2 3 4 5 6

Sleep

Trouble Falling Asleep

None 1 2 3 4 5 6

Additional Notes

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- Lowell PD Mental Performance Program
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