“Immediately following (event) did you”:		Duration
a) experience nausea or vomiting?	YES / NO	_______ h/min/sec
b) have a headache?	YES / NO	_______ h/min/sec
c) feel dizzy, have difficulty standing, or have balance problems?	YES / NO	_______ h/min/sec
d) have difficulty hearing or understanding what others were saying?	YES / NO	_______ h/min/sec
e) have problems with your vision (blurry vision, double vision, tunnel vision)?	YES / NO	_______ h/min/sec
f) see stars?	YES / NO	_______ h/min/sec
g) have difficulty speaking clearly or did others have difficulty understanding you?	YES / NO	_______ h/min/sec
h) have difficulty performing normal movements or behaviors?	YES / NO	_______ h/min/sec
i) have increased sensitivity to bright lights or loud noises?	YES / NO	_______ h/min/sec
j) Check here if no postconcussive symptoms ____