Form for TBI

Let's gather initial information

Please provide information regarding your accident. Please try to elaborate as much as possible. The worst answers are very short answers. It prevents you from being fully diagnosed, treated and prognosed.

Put your assigned number(Required)

Do not put your name for privacy reasons.

Your age?

Were you involved in a car accident?

Yes

When did the incident occur? What date?

How did the accident happen? Please describe as extensive as possible.(Required)

What type of the car where you in (make and model)?

You were?

the driver

the passenger in the front seat

the passenger in the back seat

How much was the damage to your car?

Totaled

Damaged

Did the airbags in your car go off?

Yes

The damage to my car was:

I was rear-ended.

I was T-boned.

The impact was to the front of my car.

Did you hit your head on:

Steering wheel

Dashboard

Window

Headrest

Did you lose consciousness? Loss of consciousness means being in a state like sleep.

Yes

Maybe

If you lost your consciousness, for how long?

Were you confused afterwards?

Yes

Maybe

If you were confused afterwards, for how long? Confusion means being in haze, not yourself.

Were you taken to hospital?

Yes

If you were taken to hospital, how long did you stay? Did you have any xrays, CT scans, MRIs, splinting, casting, suture, or surgery during your stay?

Any previous car accidents or work related accidents?

Now let's focus on how you feel

For the following questions, please focus on just the past week. NOT from before a week ago.

In the past week, have you had any headaches?

Yes

On average, how often does it happen? For example: Once a week, 2 times a day, once every day?

On average, how long does it last? For example: few minutes, one hour, several hours, or a whole day?

Where is it located? For example: the whole head, back of the head, temples, or front of the head?

What quality do the headaches have?

Sharp or shooting

Pressure like as if something is squeezing your head

Throbbing like a heart beating

Do you have nausea when headache is present?

Yes

Do you become sensitive to light or sound when headache is present?

Yes to both light and sound

Yes to light

Yes to sound

Do you dislike sound/music even when headache is NOT present?

Yes

Do you dislike light even when headache is NOT present?

Yes

Do you have history of headaches before the accident?

Do you have dizziness?

Yes, it is similar to lightheadedness, as if I’m going to pass out

Yes, it is similar to the feeling of spinning/movement in my head or as the room is moving

Both of the above

How long after the accident have you started driving again?

Have you had any flashbacks to the accident?

Yes

How do you drive nowadays?

Normally

Overly cautious

Now please explain the effects on Work

The following questions are regarding how the accident has affected your job or work, if applicable.

Were you working before the accident?

Yes

When did you go back to work after the accident?

If you were employed before the accident, what was your job?

Have you changed your job since the accident?

If you changed your job after accident, is the new job coming with same, more or less pay?

Have you been criticized by your associates or your supervisor about your functions, efficiency, or quality of your work?

Yes

Effects on School and Academics

The following questions are regarding how the accident affected your school and academics, if applicable.

Were you in school when the accident happened?

Yes

If you were in school, did your scores or grades deteriorate?

Yes

Personal Life

The following questions are regarding how the accident affected your personal life, such as social interactions, hobbies, etc.

Who do you live with?

How are your interactions with the people you live with? For example: more fights, conflicts, quibbles, or less open to criticism?

How are your social interactions?

Do you enjoy the same fun activities as before? Going to the mall, gatherings, parties, restaurants? Hobbies?

Yes

Changes in Mental Health and Other Symptoms

The following questions are regarding how the accident has affected your mental health, vision, sleep, etc.

Do you feel depressed? For example: feeling like you need to cry often or lacking motivation?

Yes

Do you feel frustrated, impatient or restless?

Yes

Any blurred vision?

Any double vision?

Any ringing in your ears?

How is your sleep quality?

Do you have any issues falling asleep?

Yes

Do you wake up in the middle of the night?

Yes

Any frequent nightmares started after accident?

Yes

Do you feel fatigue or tiredness during the day?

Yes

How is your focus and concentration?

Good

Poor

How is your memory?

Good

Poor

If you have poor memory, is it about recent events, such as the location of your car key or cell phone, or more about events that happened months or years ago?

Pain elsewhere in the body

The following questions are regarding pain you may have elsewhere due to the accident.

Do you have pain in other body parts?

Yes

If you feel pain in other body parts, please list:

Any treatment or visit by pain specialist or other doctors so far?

Yes

Any recent physical therapy or chiropractic treatements so far?

Yes

Any additional comments?

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