This questionnaire will help focus your symptom discovery for brain injury. When answering these questions, do so in light of how you are presently functioning.
- Have you been in an accident recently, say, within the last year?
- Did you hit your head? Were you shaken, or did you experience a physical impact?
- Were you taken to the hospital?
- What was your diagnosis?
- What doctors are you currently seeing?
- Were x-rays, MRI, or CT scan taken? SPECT scan?
- What medications are you currently taking? Were you given a prescription for this event?
Please read this list and indicate any problems you may be having. Remember to distinguish and notice if you had the problem or condition before the accident when evaluating if you have the condition presently. Note if it made a pre-existing issue worse.
Rate your problems on the following scale: Never, Occasionally, Sometimes, Frequently, or Always.
- Do you have more headaches since your injury? Pain in the temples or forehead?
- Do you have pain in the back of your head? Does it move forward? Are there moments of very sharp or stabbing pain that lasts for a few moments?
- Do you tire more easily, either mentally or physically? Does fatigue worsen with pressured thinking or emotional situations?
- Are your neck and shoulders beginning to hurt? Tingling down your arms? Overall aching feeling? Overall pain upon waking in the morning?
- Are you overly sensitive to light, sound, motion, or intense environments? Do you have dark spots before you eyes or blurred vision? Does it get worse with fatigue?
- Do you lose or misplace items?
- Do you forget what people tell you? Or what you have said to others?
- Do you forget where you parked your car? Or your current driving destination?
- Do you forget what you’ve read? Or the last TV or radio topic?
- Are you having difficulty remembering life details from the past?
Attention and Concentration
- Are you having trouble concentrating? Holding a thought?
- Do you have difficulty concentrating in noisy or strongly lit environments?
- Do you have difficulty concentrating on more than one topic or task at a time?
- Do you have difficulty focusing your attention while reading or watching TV?
- Are you having difficulty staying focused when you are driving?
- Do you have difficulty making decisions? Or remembering what you decided?
- Do you drift off in conversation, unable to recall what has been said?
- Is it stressful to read and answer this questionnaire?
- Are you easily distracted? When interrupted, do you struggle to find your place again or return to your task?
- Have you become impulsive, making decisions or remarks without thinking them through? Unintentionally hurting someone’s feelings? Impulse shopping?
Language and Communication
- Do you have difficulty following a conversation?
- Do you have difficulty thinking of the exact word or words you want to use?
- Do you have problems expressing yourself in writing?
- Is it difficult conversing with others or staying in a conversation?
- Are you struggling to spell words? Do you reverse the letters?
- Are you pronouncing words correctly? Is your tongue twisting words around or relocating words inaccurately in a sentence?
- Do you have increased sensitivity to light, sound, shopping, party, or large meeting environments?
- Do objects seem closer or farther away than they actually are?
- When reading, do printed letters appear to change their shape or position on the page? Are you experiencing eye strain or headaches when reading?
- Do you have difficulty focusing your eyes on objects?
- Do you feel dizzy or nauseous? Are you bumping into objects more than usual? Whacking your elbows, hitting your head, or stubbing your toes frequently?
- Do your eyes struggle to track written text or follow moving objects?
- Do you have difficulty following through with planning for work or leisure activities? Do you accurately gauge the time a task will take?
- Do you have problems setting goals and priorities and keeping to your plan?
- Do you have difficulty starting new tasks? Does a new task trigger depression, hopelessness or fatigue? Do you struggle to get in the mood to begin?
- Do you have difficulty monitoring and correcting your errors?
- Do you have difficulty changing from one task to another?
- Are you able to anticipate the consequences of your actions? Can you foresee outcomes or project the future of a task.
- Are you checking and rechecking your work? Does the slightest disruption in your routine derail you?
- Are you unintentionally repeating yourself in conversation?
- Have you noticed frequent mood swings or emotional outbursts?
- Do you have difficulty handling your anger?
- Do you feel depressed? Are you fearful? Have you lost hope? Are you tired of fighting for recovery? Just want your life back the way it was?
- Do you have feelings of anxiety, jumpiness, or nervousness?
- Do family and friends comment on changes in your behavior? Are people living around you on the outskirts of you?
- Trouble sleeping? Poor appetite or binge eating? Craving stimulant foods?
- Do you feel hopeless, although you can identify things that are hopeful or positive? Does hope feel just out of your reach?
- Have you become gullible? Easily distractible or unintentionally naïve? Can you tell when you are being teased, and do you respond with humor?
- Are you easily startled, agitated, or irritated? Do you respond with aggression? Feel tense or wound up all the time? Overly sensitive to your environment?
Finances and Measurements
- Do you have difficulty easily performing simple addition and subtraction?
- Can you easily make change at the store?
- Do you struggle to balance your checkbook as accurately as before?
- Do you remember to open your mail, sort it, and pay your bills on time?
- Can you follow a recipe easily, or comprehend and follow instructions to assemble or operate something? Can you easily follow a map or directions to a location?
Organization and Sequencing
- Do you have difficulty following the steps of a recipe?
- Do you attend to your mail on a regular basis? Can you accurately sort the junk mail and focus on mail worthy of your time and energy?
- Do you struggle with performing, initiating, or keeping up with normal, routine household chores?
- Do you have difficulty performing more than one household task at a time?
- Can you effectively manage your time? Do you lose track of time?
- Do you set priorities and fulfill your obligations?
- Do you follow through on a project to the end, or do you set it aside with good intentions, yet ultimately abandon it?
- Do you forget to turn off the iron, stove, tea pot, or other household appliances?
- Do you forget where you are going when driving your car?
- Do you forget to lock your doors at home? Do you lock your car doors? Garage door?
- Do you forget important appointments (e.g., picking up the kids, going to your doctor’s appointment, banking your paycheck)?
- Do you feel like your safety awareness levels are less than they should be?
- Has your tolerance for alcohol, caffeine, or drugs decreased?
Other quick questions you may relate to include: (Answering: Never, Occasionally, Sometimes, Frequently, and Always)
- Remembering where your keys, glasses, purse, wallet are?
- Remembering to brush your teeth, eat breakfast, and shower?
- Remembering how to do all the parts of your job?
- Do you lose track of time? Forget to eat? Forget who you just dialed on the phone?
- Are you sleeping well? Are you easily fatigued?
- Do you feel overwhelmed, or unable to cope?
- Are you intolerant of noise? Even traffic noise? Even the dishwasher?
- To have a successful conversation, must you turn off the radio or TV first?
- Are you restless? Do you worry more? Lack patience?
- Are you overwhelmed by simple pleasures, or by people you used to enjoy?
- Do you feel like you are “losing it?” Out of control? Going crazy?
- Do you hopelessly search for the word you want?
- Is your speech slurred or jumbled? Are you inventing words that get jammed into each other?
- Is your body’s temperature in control? Your appetite?
- Are there changes in your sex drive or sexual response? Is orgasm a struggle?
- Are there changes to your menses? Your sleep cycle? Digestive rhythm?
Likely, you see yourself in these questions. Somehow, your brain and emotional functions are different than they were before your incident. You need to know that you are not alone, and you are not crazy. There are actions you can take to enhance your mending process and to maximize your brain’s opportunity to recover and function to its highest potential.
From BrainLash: Maximize Your Recovery from Mild Brain Injury, Third Edition by Gail L. Denton, PhD. Demos Medical Publishing, 2008. Reprinted with permission. All rights reserved. www.demosmedpub.com.