Neuro Severity Rating

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Neuro Severity Rating
Please complete the required fields and then rate each symptom from 0-6 with how you have been feeling for the past week.
 
0: None   1: Mild    2: High Mild     3: Moderate   
4: High Moderate    5: Severe  6: High Severe

"*" indicates required fields

This field is for validation purposes and should be left unchanged.
MM slash DD slash YYYY
Reading - Check all that apply
Academic - Check all that apply
Ocular Symptoms - Check all that apply
Emotional and Behavioral - Check all that apply
Localization and Navigation - Check all that apply
Please do not submit any Protected Health Information (PHI)

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