In 90 seconds you’ll find out your concussion ‘type’ and how to heal it!

Concussion Quiz

Name(Required)

First Last

Email(Required)

How did you hear about 4D vision gym(Required)

How long ago was your injury?(Required)

Less than 2 Months

More than 2 Months

How long ago was your last eye exam?(Required)

Has the patient been diagnosed with a concussion?(Required)

Yes

No

Has the patient received any type of therapy?(Required)

Yes

No

Concussion Symptoms checklist(Required)

Headache

Dizziness when stationary

Fatigue

Sensitivity to sound/noise

Not like normal self

Vision changes

Trouble recognising familiar people

Loss of consciousness

Difficulty concentrating

Increased sadness

Depression

Nervousness

Trouble falling asleep

Sleeping more than usual

Nausea or vomiting

Dizziness when moving

Sensitivity to light

Moving slowly

Hearing problems/ ringing in the ears

Slurred speech

Fluid from ears and/or nose

Mentally Foggy

Difficulty remembering recent or past information

More emotional than usual

Increased irritability

Excess drowsiness

Trouble staying asleep

Sleeping less that usual

Would you like to receive 4D Vision Gym’s newsletter, updates and special events via email?(Required)

Yes

No

Accessibility by WAH

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