Use slider to rate symptoms between 0 to 6 0=none, 1-2 = mild, 3-4 = moderate, 5-6 = severe Please enable JavaScript in your browser to complete this form.Headache Selected Value: 0 Pressure in Head Selected Value: 0 Neck Pain Selected Value: 0 Nausea or vomiting Selected Value: 0 Dizziness Selected Value: 0 Blurred vision Selected Value: 0 Balance problems Selected Value: 0 Sensitivity to light Selected Value: 0 Sensitivity to noise Selected Value: 0 Feeling slowed down Selected Value: 0 Feeling like in a fog Selected Value: 0 Don't feel right Selected Value: 0 Difficulty concentrating Selected Value: 0 Difficulty remembering Selected Value: 0 Fatigue or low energy Selected Value: 0 Confusion Selected Value: 0 Drowsiness Selected Value: 0 More emotional Selected Value: 0 Irritability Selected Value: 0 Sadness Selected Value: 0 Nervous or Anxious Selected Value: 0 Trouble falling asleep Selected Value: 0 Additional commentsSubmit88865