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Suzanne Rosenberg, MD
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Concussion Information for Families
Concussion Patient Intake
Medical History--All patients please complete
Patient Information-- All patients please complete
Concussion Patient Intake
Name
Today's Date
Nature of Injury
How did you get hurt? Where did you hit your head? Was it witnessed?
Do you remember the injury?
Yes
No
Are there events before of after the injury you cannot recall?
Before
After
No loss of memory
Was there a loss of consciousness?
Yes
No
Unsure
Please click CURRENT Physical symptoms
Headache
Nausea
Vomiting
Balance problems
Dizziness
Vision Problems
Fatigue
Light Sensitivity
Sound Sensitivity
Numbness/tingling
Please click CURRENT Cognitive symptoms
Feeling foggy
Feeling slowed down
Difficulty Concentrating
Difficulty Remembering
Please click CURRENT Emotional symptoms
Irritability
Sadness
More emotional
Nervousness
Please click CURRENT Sleep symptoms
Drowsiness
Sleeping less than usual
Sleeping more than usual
Trouble falling asleep
Do Symptoms worsen with physical activity
YES
NO
Do Symptoms worsen with cognitive activity (thinking)
Yes
No
Risk factors for Recovery
Please list prior concussions
Headache history
How often did you have headaches prior to this injury?
Is there a history of headaches in the family?
Developmental history
Learning disability
Attention Deficit or Hyperactivity
Mood Disorder
Check all that apply
* Required field
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