My Concussion Evaluation

-


Concussion Initial Evaluation:
Patient Name:

Date of Birth:
Subjective:
DOI:

Presence of Red Flags (Y/N):
MOI:

Imaging:

Medications:
History:

(Y/N)
Description
Previous concussions 

Total Number:

Dates:

History of Migraines (Y/N):

Aura:
Triggers:
Allergies


Medications
Neurocognitive Baseline Hx
Completed (Y/N)
Date Completed
Location completed
Pass / Fail
Baseline Neurocognitive Testing Completed (ImPACT)




Neurocognitive Testing Completed Post-Injury
Concussion Symptom Checklist
Please report your symptoms on the following scale: 0 = no symptoms; 6 = severe symptoms. 
If you are being seen post-injury please fill out based on how you feel at this moment in time.
If you are being seen for baseline screening, please fill out based on how you typically feel.
Baseline or Post injury:

None
Mild
Moderate
Severe
Headache
0
1
2
3
4
5
6
“Pressure in the head”
0
1
2
3
4
5
6
Neck Pain
0
1
2
3
4
5
6
Nausea or Vomiting
0
1
2
3
4
5
6
Dizziness
0
1
2
3
4
5
6
Blurred Vision
0
1
2
3
4
5
6
Balance Problems
0
1
2
3
4
5
6
Sensitivity to Light
0
1
2
3
4
5
6
Sensitivity to Noise
0
1
2
3
4
5
6
Feeling Slowed Down
0
1
2
3
4
5
6
Feeling like “in a fog”
0
1
2
3
4
5
6
“Don’t Feel Right”
0
1
2
3
4
5
6
Difficulty Concentrating
0
1
2
3
4
5
6
Difficulty Remembering
0
1
2
3
4
5
6
Fatigue or Low Energy
0
1
2
3
4
5
6
Confusion
0
1
2
3
4
5
6
Drowsiness
0
1
2
3
4
5
6
More Emotional
0
1
2
3
4
5
6
Irritability
0
1
2
3
4
5
6
Sadness
0
1
2
3
4
5
6
Nervous or Anxious
0
1
2
3
4
5
6
Trouble Falling Asleep
0
1
2
3
4
5
6
Total Number of Symptoms
of 22

Symptom Severity Score
of 132

Do your symptoms worsen with physical activity?
Yes          No
If 100% is feeling normal, what percent of normal do you feel?
If not 100%, why?
Adapted from SCAT 5
Sport concussion assessment tool - 5th editionBritish Journal of Sports Medicine 2017;51:851-858.
Objective:
Cervical Spine Assessment
Upper Cervical Ligament Instability Testing
Test
Sharps Purser
C2 Kick
Transverse Ligament
(+ / -)
Cervical ROM
ROM (degrees)
Symptom reproduction w/ prolonged hold (Y/N) - Describe
Flexion


Extension


Right Side Bend


Left Side Bend


Right Rotation


Left Rotation


Posterior Right Quadrant


Posterior Left Quadrant
Cervical Spine Special Testing
Positive / Negative (+/-)
Comments
Deep Neck Flexor Endurance

Time (seconds): 
Cervical Flexion-Rotation Test


Head Neck Differentiation Test


Smooth-Pursuit Neck Torsion Test
Balance Error Scoring System (BESS)
Firm Surface
Number of Errors
Foam Surface
Number of Errors
Double leg Stance 
(feet together)

Double leg Stance 
(feet together)

Single leg Stance
(non-dominant foot)

Single leg Stance
(non-dominant foot)

Tandem Stance
(non-dominant foot in back)

Tandem Stance
(non-dominant foot in back)

Total Errors

Total Errors

Sum of Total Errors
Types of Errors: 1 point given for each error
Hands lifted off iliac crest
Opening eyes
Step, stumble, or fall
Abduction or flexion of the hip beyond 30 degrees
Lifting forefoot or heel from testing surface
Remaining out of testing position for > 5 seconds
Postural Orthostatic Tachycardia Syndrome:
Condition
Heart Rate
Blood Pressure
Symptoms
After supine for 10 min



Immediate Standing



Standing 3 min



Standing 5 min



Standing 10 min
Age
Diagnostic Criteria
Present (Y/N)
Adolescents 12-19
HR increase > 40 bpm or sustained orthostatic HR > 120 bpm 
<20/10 mm Hg change in BP
*
Adults > 19
HR increase >30 bpm or sustained orthostatic HR >120 bpm 
<20/10 mm Hg change in BP
*
*  If yes, borderline, or if there is any suspicion of abnormality refer back to the physician.
Vestibular Ocular Motor Screening (VOMS):

Not Tested
Headache (0-10)
Dizziness (0-10)
Nausea (0-10)
Fogginess (0-10)
Comments
Baseline Symptoms






Smooth Pursuits






Saccades - Horizontal 






Saccades - Vertical






Convergence (Near Point)





Near Point (cm)
Measure 1: _____
Measure 2: _____
Measure 3: _____
VOR  - Horizontal






VOR - Vertical






Visual Motion Sensitivity
BPPV Assessment:
Test
(+ / -)
Comments
Dix - Hallpike
R:
L:

Roll Test
R:
L:
Additional Ocular Assessment: 
Assessment
Abnormalities / Description / Assessment
Visual Acuity

Refer worse than 20/25
Dynamic Visual Acuity

Positive is > 3 line loss
Binocular Visual Field Deficit

Note suspected quadrant if (+)
Monocular Visual Field Deficit
R:
L:
Binocular Smooth Pursuit H and I testing

Monocular Smooth Pursuit H and I testing
R:
L:
Binocular Near Point /  Far Point

Monocular Near Point / Far Point
R: 
L:
Monocular Saccades
R:
L:
Benefit from Binocular Occlusion

Ocular Headache Pattern

If yes, teach eye recovery
Buffalo Concussion Treadmill Test
Minute
HR (bpm)
RPE
Likert Scale
Symptoms
Comments
Baseline





1





2





3





4





5





6





7





8





9





10





11





12





13





14





15





16





17





18





19





20





1’ Post





2’ Post
Other Assessments / Notes:
Assessment:
Limiting Profile
Cervical
Vestibular
Exertion
Ocular
Cognitive
Migraine
Anxiety / Mood
Y/N/TBA
ICD 10 Codes:
Code:
Description:
Code:
Description:
Goals:
Short Term Goal
Time Frame (weeks)
Asymptomatic VOMS

BESS < 12 Errors

BCTT > 10’ asymptomatic

No symptoms with sustained neck positioning

Deep neck flexor endurance > 35”

Other:

Other:
Long Term Goal
Time Frame (weeks)
No symptoms w/ BCTT

Full sport specific conditioning asymptomatic

No symptoms with all cognitive tasks

No symptoms for 3 consecutive days with all activities including work and recreation

Other:

Other:
Plan:
Practitioner Name:

Physical Therapist License Number:

Signature:


Comments

Post a Comment