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Rivermead Survey
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DIRECTIONS: Answer every question by filling in the correct circle or writing in the information. If you need to changes an answer, completely erase the incorrect mark and fill in the correct circle. If you are unsure about how to answer a question, please give the best answer you can.
Mark only one answer for each question.
Patient Name:
Date
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To be completed by the PATIENT
Headache – more often or longer lasting:
Dizziness:
Problems with sleep – more tired, trouble sleeping:
Feeling sad, more emotional or depressed:
Trouble thinking, taking more time to think:
Trouble concentrating – harder to focus:
Fatigue, tire easily:
Double or blurry vision:
Sensitive to noise:
Sensitive to light:
Trouble with memory, forgetful:
Easily irritated –frustrated, impatient, angry:
Loss of balance:
Trouble with hearing:
Trouble with taste:
Trouble with smell:
Feeling like the room is spinning:
Feeling restless, nervous or worried:
Nausea or vomiting:
Compared with before your injury, do you now have the following complaints?
Please rate on the scale below.
No more of a problem
Mild Problem
Moderate problem
Severe Problem Never
been a problem
Continued on back....
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Numbness or tingling in parts of your body:
Difficulty making decisions:
Mild Problem
Moderate problem
Severe Problem Never
been a problem
No more of a problem
Takes longer or more effort to do things that were once easy:
More energy than usual:
