Checklist of Symptoms of Head Injury following Trauma
Please review this form and check the appropriate boxes to indicate whether and to what degree you have experienced any of the following symptoms since your injury:
Mild |
Moderate |
Severe |
Preexisting Problem |
Comments |
|
| Loss of Consciousness | |||||
| Headaches | |||||
| Vomiting | |||||
| Dizziness | |||||
| Fatigue | |||||
| Blurred Vision | |||||
| Confusion | |||||
| Sleep Disorder | |||||
| Memory Loss | |||||
| Amnesia | |||||
| Irritability | |||||
| Concentration Loss | |||||
| Sensitivity to Noise | |||||
| Temperament Change | |||||
| Loss of Motivation | |||||
| Speech Problems (Word Finding) | |||||
| Speech Problems (Pronouncing Words) | |||||
| Unable to Control Emotions | |||||
| Loss of Math Ability | |||||
| Sexual Dysfunction |
Do you have difficulty remembering names, your telephone number, your birth date or those of family members?
Can you repeat a series of numbers given to you?
Do you have any recollection of the accident, or events before of after it?
