Please rate the following symptoms with regard to how much they have disturbed you IN THE LAST 2 Weeks. The purpose of this inventory is to track symptoms over time. Please do not attempt to score.

0 = None – Rarely if ever present; not a problem at all.

1 = Mild – Occasionally present, but it does not disrupt my activities; I can usually continue what I’m doing; doesn’t really concern me.

2 = Moderate – Often present, occasionally disrupts my activities; I can usually continue what I’m doing with some effort; I feel somewhat concerned.

3 = Severe – Frequently present and disrupts activities; I can only do things that are fairly simple or take little effort; I feel I need help.

4 = Very Severe – Almost always present and I have been unable to perform at work, school or home due to this problem; I probably cannot function without help.
0 1 2 3 4
Feeling Dizzy  
Loss of balance
Poor coordination, clumsy
Vision problems, blurring, trouble seeing
Sensitivity to light
Hearing difficulty
Sensitivity to noise
Numbness or tingling on parts of my body
Change in taste and/or smell
Loss of appetite or increased appetite
Poor concentration, can’t pay attention, easily distracted
Forgetfulness, can’t remember things
Difficulty making decisions
Slowed thinking, difficulty getting organized, can’t finish things
Fatigue, loss of energy, getting tired easily
Difficulty falling or staying asleep
Feeling anxious or tense
Feeling depressed or sad
Irritability, easily annoyed
Poor frustration tolerance, feeling easily overwhelmed by things
Used with permission: Cicerone,KD: J Head Tr Rehabil 1995;10(3):1-17

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