Concussion Intake Form - Concussion Recovery Clinics

Background

Name*

First Last

Gender

Age

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Injury

Please describe Intensity and Duration of Concussion symptoms (if present) :

Describe Injury:

Treatments tried before:

Medications Used:

Score yourself on the severity of the following symptoms 0 (None) - 10 (Extreme)

Headaches

Ringing in ears

Pain level

Brain fog

Other general symptoms: