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Home » Patient Forms » Concussion Patient Form

Concussion Patient Form

Name: Visual Symptoms Treatment Center
Address: 3250 N. Arlington Heights Rd, Ste 109, Arlington Heights, IL, 60004, US
Telephone: 847-255-1040
Price range: $000 - $300

PATIENT FORM — CONCUSSION

Patient Name:

First Last

DOB:

MM slash DD slash YYYY

Date

MM slash DD slash YYYY

Were you referred to our office?

Yes

No

Who Referred You?

Please fill out name, location, & contact information of the referral source.

Name of professional who referred you:

Address of professional who referred you:

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

Phone

Fax

Email

Do we have permission to communicate findings with referral source?

Yes

No

When was your last injury?

Explain how the injury happened:

What part of your head was injured?

Were you treated by any other professionals for this injury?

Yes

No

Please explain:

Was there a previous injury?

Yes

No

when did it occur and how did it happen?

Did you have a CAT Scan or an MRI?

Yes

No

what were the results?

Was there a neurologic consult?

Yes

No

Was there a medical consult?

Yes

No

Were you hospitalized:

Yes

No

for how long?

Did you experience any loss of consciousness?

Yes

No

Are you experiencing any dizziness?

Yes

No

Frequency

Do you know what causes them?

Are you experiencing any headaches?

Yes

No

Frequency

Does anything seem to cause them?

What area of the head gets headaches?

Please rate your headache level 1 to 10

Nausea?

Yes

No

Ringing in the ears?

Yes

No

Balance problems?

Yes

No

Double Vision?

Yes

No

Blurry vision?

Yes

No

Reading:

Can you read comfortably

Yes

No

For how long?

Do you experience loss of place, skipping words, words moving on the page?

Yes

No

Do you experience symptoms of headaches, nausea, dizziness, blurry vison, double vision, loss of place now?

Yes

No

How long can you read before getting symptoms?

How long does it take to recover from symptoms?

Is it worse on paper or on an electronic screen?

Please explain:

Motion Sensitivity:

Do you experience

disorientation

dizziness

nausea

headaches in Malls, Grocery Stores?

Restaurants, Airports

Classroom

Hallways

Crowds

Light Sensitivity:

Inside:

Yes

No

Outside:

Yes

No

Fluorescent Lights:

Yes

No

Car Sickness:

Did you experience car sickness after the injury:

Yes

No

Do you experience car sickness when you are the driver?

Yes

No

How long of a drive in the car before you experience the car sickness?

FOR SCHOOL OR COLLEGE STUDENTS:

Do you have any accommodations at school?

Yes

No

What are they?

FOR WORK ENVIRONMENT:

Do you have any accommodations in your work environment?

Yes

No

What are they?

PHYSICAL ACTIVITY:

Are you restricted in your physical activities?

Yes

No

In what way?

REHABILITATION THERAPY:

What rehabilitation therapy have you had?

Name of Provider/Facility

What are the names and specialties of providers following/ managing your care?

LIST OF MEDICATION/VITAMINS YOU ARE TAKING

How often:

NAME, TOWN AND PHONE NUMBER OF THE FOLLOWING PROVIDERS IF APPLICABLE:

Name of the PRIMARY CARE DOCTOR:

First Last

Phone

TOWN

Name of the PSYCHOLOGIST:

First Last

Phone

TOWN

Name of the SPORTS DOCTOR:

First Last

Phone

TOWN

Name of the PHYSIATRIST:

First Last

Phone

TOWN

Name of the NEUROLOGIST:

First Last

Phone

TOWN

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Visual Symptoms Treatment Center

3250 N. Arlington Heights Rd, Ste 109
Arlington Heights, IL 60004

Phone: 847-255-1040

Monday: 9:00 AM - 7:00 PM
Tuesday: 9:00 AM - 6:00 PM
Wednesday: Closed
Thursday: 9:00 AM - 6:00 PM
Friday: 9:00 AM - 7:00 PM
Saturday: 8:00 AM - 2:15 PM
Sunday: Closed

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About Us
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Hours+Location
About Us
Advanced Services
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For Patients