ELEZ01 The Rivermead Post-Concussion Symptoms Questionnaire

The Rivermead Post-Concussion Symptoms Questionnaire

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Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Date of Injury*
Form A: State of Symptoms for the First 7 Days Following the Injury

After a head injury or accident some people experience symptoms which can cause worry or nuisance. We would like to know if you now suffer from any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one, please circle the number closest to your answer.

0 = Not experienced at all 1 = No more of a problem 2 = A mild problem

3 = A moderate problem 4 = A severe problem

Form A: State of Symptoms for the First 7 Days Following the Injury: Compared with before the accident, did you immediately following the accident (i.e., over the next 7 days) suffer from:

	0=Not experienced at all	1=No more of a problem	2=A mild problem	3=A moderate problem	4=A severe problem
Headaches
Feelings of Dizziness
Nausea and/or Vomiting
Noise Sensitivity, easily upset by loud noise
Sleep Disturbance
Fatigue, tiring more easily
Being Irritable, easily angered
Feeling Depressed or Tearful
Feeling Frustrated or Impatient
Forgetfulness, poor memory
Poor Concentration
Taking Longer to Think
Blurred Vision
Light Sensitivity, easily upset by bright light
Double Vision
Restlessness

Are you experiencing any other difficulties not listed above?

YesNo
1. If yes, what are they?
How would you rate them?

0=Not experienced at all1=No more of a problem2=A mild problem3=A moderate problem4=A severe problem
Form B: Current State of Symptoms

After a head injury or accident some people experience symptoms which can cause worry or nuisance. We would like to know if you now suffer from any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one, please circle the number closest to your answer.

0 = Not experienced at all 1 = No more of a problem 2 = A mild problem
3 = A moderate problem 4 = A severe problem

Form B: Current State of Symptoms: Compared with before the accident, do you NOW (over the last 24 hours) suffer from:

	0=Not experienced at all	1=No more of a problem	2=A mild problem	3=A moderate problem	4=A severe problem
Headaches
Feelings of Dizziness
Nausea and/or Vomiting
Noise Sensitivity, easily upset by loud noise
Sleep Disturbance
Fatigue, tiring more easily
Being Irritable, easily angered
Feeling Depressed or Tearful
Feeling Frustrated or Impatient
Forgetfulness, poor memory
Poor Concentration
Taking Longer to Think
Blurred Vision
Light Sensitivity, easily upset by bright light
Double Vision
Restlessness

Are you experiencing any other difficulties not listed above?

YesNo
1. If yes, what are they?
How would you rate them?

0=Not experienced at all1=No more of a problem2=A mild problem3=A moderate problem4=A severe problem
Should be Empty: