Symptom Checklist Form, Medical Symptom Checklists

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Queries

The following is a list of difficulties and feelings which people sometimes have after an injury. Please indicate which ones you have experienced since your injury by ticking the column. If you have not experienced the symptom since your recent injury, leave it blank. Thank you!

SYMPTOM Yes/No

Often have headaches

Difficulty remembering

Have felt depressed or find difficulty becoming interested in anything

Often lose temper or get upset more easily than before

Often feel anxious or tense

Suffer from dizziness

Have difficulty concentrating, reading or following a conversation

Have difficulty with eyes

Often troubled by too much noise

Have difficulty speaking

Often irritable or angry