Synapse TBI – Traumatic Brain Injury Testing

Name

Address

Phone

Date

Physician Name

Assessment Type

Physical Symptoms

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Headache

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Nausea

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Vomiting

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Dizziness

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Blurry or double vision

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Sensitivity to light

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Sensitivity to noise

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Balance problems

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Pain other than headache

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Thinking/ Cognitive & Sleep Issues

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Feeling slowed down

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Difficulty concentrating

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Difficulty remembering

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Trouble falling asleep

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Fatigue or low energy

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Drowsiness

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Feeling “in a fog”

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Emotional Symptoms

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Feeling more emotional

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Irritability

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Sadness

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Please indicate how much each symptom has bothered you over the past 2 days on a scale from 0-6 zero being none & 6 being severe.

Nervousness

0 (None)

1 (Mild)

2 (Mild)

3 (Moderate)

4 (Moderate)

5 (Severe)

6 (Severe)

Rivermead Post Concussion Symptoms

Compared with before, do you now (i.e, over the last 24 hours) suffer from

Headaches

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Feelings of Dizziness

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Nausea and/or vomiting

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Noise Sensitivity, easily upset by loud noise

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Sleep Disturbance

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Fatigue, tired easily

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Being Irritable, easily angered

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Feeling depressed or tearful

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Feeling frustrated or impatient

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Forgetfulness, poor memory

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Poor Concentration

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Taking longer to think

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Blurred vision

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Light sensitivity, easily upset by bright light

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Double vision

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem

Compared with before, do you now (i.e, over the last 24 hours) suffer from:

Restlessness

0= Not experienced at all

1= No more of a problem

2= A mild problem

3= A moderate problem

4= A severe problem