Concussion Rehabilitation Assessment

Inspection template for documenting concussion symptoms, balance findings, and cognitive screening results to guide rehabilitation, monitor recovery, and assess return-to-activity readiness.

Assessment Details

• Assessment type
  Identify whether this is a baseline, acute, follow-up, or clearance-related assessment.
• Days since injury
  Enter the number of days since the suspected or confirmed concussion event.
• Assessment setting
  Document where the assessment was performed.
• Baseline comparison available
  Indicate whether pre-injury baseline testing or prior assessment results are available for comparison.
• Relevant prior concussion history documented
  Confirm whether prior concussion history and recovery pattern have been reviewed.

Symptom Burden

• Overall symptom severity score
  Record the total symptom severity score using the clinic's chosen concussion symptom scale.
• Number of symptoms reported
  Record the total number of symptoms currently reported by the patient.
• Headache severity
  Rate headache severity during the assessment.
• Dizziness or balance-related symptom severity
  Rate dizziness, vertigo, or imbalance symptoms.
• Light sensitivity severity
  Rate photophobia or light sensitivity symptoms.
• Noise sensitivity severity
  Rate phonophobia or noise sensitivity symptoms.

Balance and Vestibular Screening

• Single-leg stance maintained without loss of balance
  Observe whether the patient can maintain single-leg stance for the clinic-defined duration without stepping, swaying excessively, or requiring support.
• Tandem gait performed without deviation
  Assess whether tandem gait is completed without stepping off line, pausing, or needing assistance.
• Romberg stance stability
  Rate postural stability during Romberg stance or equivalent balance testing.
• Vestibular symptom provocation during testing
  Indicate whether balance or head-movement testing provoked dizziness, nausea, blurred vision, or symptom worsening.
• Gait observed as normal and safe
  Confirm whether gait is steady, safe, and appropriate for the environment without assistive support.

Cognitive Screening

• Orientation intact
  Confirm orientation to person, place, time, and situation.
• Immediate recall performance
  Record the number of words or items correctly recalled immediately, based on the selected screening tool.
• Attention and concentration adequate for screening
  Indicate whether the patient could sustain attention and complete cognitive tasks without excessive prompting or distraction.
• Delayed recall performance
  Record delayed recall results using the clinic's chosen cognitive screening method.
• Cognitive symptoms worsened during screening
  Document whether screening triggered headache, fogginess, slowed thinking, or other symptom worsening.

Return-to-Activity Readiness

• Symptoms at rest are minimal or absent
  Confirm whether symptoms at rest are minimal enough to support progression in the return-to-activity plan.
• Symptoms do not worsen with light activity
  Indicate whether the patient tolerated light physical or cognitive activity without symptom exacerbation.
• Return-to-activity recommendation
  Select the current recommendation based on symptoms, balance, and cognitive findings.