SCAT-5 Symptom Questionaire
Patient:
Date:
Instructions:
Read the following instructions out loud.
The athlete should be given the symptom form and asked to read this instruction paragraph out loud then complete the symptom scale. For the baseline assessment, the athlete should rate his/her symptoms based on how he/she typically feels and for the post injury assessment the athlete should rate their symptoms at this point in time.
Currently how much are you bothered by:
none (0)
mild (1-2)
moderate (3-4)
severe (5-6)
Q1. Headache?
0
1
2
3
4
5
6
Q2. "Pressure in the head"?
0
1
2
3
4
5
6
Q3. Neck Pain?
0
1
2
3
4
5
6
Q4. Nausea or vomiting?
0
1
2
3
4
5
6
Q5. Dizziness?
0
1
2
3
4
5
6
Q6. Blurred vision?
0
1
2
3
4
5
6
Q7. Balance problems?
0
1
2
3
4
5
6
Q8. Sensitivity to light?
0
1
2
3
4
5
6
Q9. Sensitivity to noise?
0
1
2
3
4
5
6
Q10. Feeling slowed down?
0
1
2
3
4
5
6
Q11. Feeling like "in a fog"?
0
1
2
3
4
5
6
Q12. "Don't feel right"?
0
1
2
3
4
5
6
Q13. Difficulty concentrating?
0
1
2
3
4
5
6
Q14. Difficulty remembering?
0
1
2
3
4
5
6
Q15. Fatigue or low energy?
0
1
2
3
4
5
6
Q16. Confusion?
0
1
2
3
4
5
6
Q17. Drowsiness?
0
1
2
3
4
5
6
Q18. More Emotional?
0
1
2
3
4
5
6
Q19. Irritability?
0
1
2
3
4
5
6
Q20. Sadness?
0
1
2
3
4
5
6
Q21. Nervous or Anxious?
0
1
2
3
4
5
6
Q22. Trouble falling asleep?
0
1
2
3
4
5
6
Total number of symptoms:
Total severity score:
Interpretation:
The Sport Concussion Assessment Tool symptom checklist, (SCAT-5):
Reference
Subject: