The Concussion Quiz

Are you 18 years or older?*

What is your first name?*

What is your last name?*

What is your phone number?*

What is your email?*

Their Name*

First Last

Guardian Name*

First Last

Guardian Phone*

Guardian Email*

Did an object hit your head?

Did you fall and hit your head?

Did your head make contact with another person?

What part of the head did the impact occur?

Are you sensitive to noise or light?

Are you having a hard time concentrating at work and/or school?

Are you having persistent headaches?

Do you feel like you're reading slower than usual?

Do you develop headaches or eye pain when reading?

Do you have difficulty looking at your computer or other screens?

Do you have complaints of dizziness?

Do you feel off-balanced or clumsy?

State/Zip (This will help us guide you to the closest Athletico location that offers the treatment you need)*

State ZIP Code

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Comments

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