Scale: 0 for none
           1 for minor
           2 for mild
           3 or 4 for moderate
           5 or 6 for severe
Rate daily before activities and after or morning and late in the day	
	Date/Time
Activity:
___________________________
_________	Date/Time
Activity:
___________________________
_________	Date/Time
Activity:
___________________________
_________	Date/Time
Activity:
___________________________
_________	Date/Time
Activity:
___________________________
_________	Date/Time
Activity:
___________________________
_________	Date/Time
Activity:
___________________________
_________	
Symptom								
Headache								
Nausea								
Vomiting								
Balance Problems								
Dizziness								
Fatigue								
Trouble Falling Asleep								
Sleeping More than Usual								
Sleeping Less than Usual								
Drowsiness								
Sensitivity to Light								
Sensitivity to Noise								
Irritability								
Sadness								
Nervousness								
Feeling More Emotional								
Numbness or Tingling								
Feeling Slowed Down								
Feeling Mentally Foggy								
Difficulty Concentrating								
Difficulty Remembering 								
Visual Problems