Common Indicators of a Head Injury

This questionnaire is not meant to be a formal "test" to see if you have a head injury. If you have multiple "YES" answers, bring this questionnaire to your doctor. Additional tests (medical and neuropsychological) maybe ordered.

HEADACHES
Yes
No
Do you have more headaches since the injury or accident?
Yes
No
Do you have pain in the temples or forehead?
Yes
No
Do you have pain in the back of the head

(sometimes the pain will start at the back of the head and extend to the front of the head)?
Yes
No
Do you have episodes of very sharp pain (like being stabbed)

in the head which lasts from several seconds to several minutes?
MEMORY
Yes
No
Does your memory seem worse following the accident or injury?
Yes
No
Do you seem to forget what people have told you 15 to 30 minutes ago?
Yes
No
Do family members or friends say that you have asked the same question over and over?
Yes
No
Do you have difficulty remembering what you have just read?
WORD-FINDING
Yes
No
Do you have difficulty coming up with the right word

(you know the word that you want to say but can’t seem to "spit it out")?
FATIGUE
Yes
No
Do you get tired more easily (mentally and/or physically)?
Yes
No
Does the fatigue get worse the more you think or in very emotional situations?
CHANGES IN EMOTION
Yes
No
Are you more easily irritated or angered (seems to come on quickly)?
Yes
No
Since the injury, do you cry or become depressed more easily?
CHANGES IN SLEEP
Yes
No
Do you keep waking up throughout the night and early morning?
Yes
No
Do you wake up early in the morning (4 or 5 a.m.) and can’t get back to sleep?
ENVIRONMENTAL OVERLOAD
Yes
No
Do you find yourself easily overwhelmed in noisy or crowded places (feeling overwhelmed in a busy store or around noisy children)?
IMPULSIVENESS
Yes
No
Do you find yourself making poor or impulsive decisions (saying things "without thinking" that may hurt others feelings; increase in impulse buying?)
CONCENTRATION
Yes
No
Do you have difficulty concentrating (can’t seem to stay focused on what you are doing)?
DISTRACTION
Yes
No
Are you easily distracted (someone interrupts you while you are doing a task and you lose your place)?
ORGANIZATION
Yes
No
Do you have difficulty getting organized or completing a task (leave out a step in a recipe or started multiple projects but don’t complete them)?

__________ Total Number of Yes Answers
If you have 5 or more Yes answers, discuss the results of this questionnaire with your doctor.

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For more great infomation visit: http://www.tbiguide.com/

To obtain a copy of:
TRAUMATIC BRAIN INJURY SURVIVAL GUIDE
Contact: Dr. Glen Johnson, Clinical Neuropsychologist
Clinical Director of the Neuro-Recovery Head Injury Program

5123 North Royal Drive Traverse City, MI 49684
Phone 231-935-0388 Email debglen@yahoo.com
Website http://www.tbiguide.com/
Copyright ©1998 Dr. Glen Johnson. All Rights Reserved.