Military Head Injury Evaluation Form
Complete this form to assess and document a head injury incident in a military setting.
Service Member's Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Rank/Position
*
Unit/Division
*
Date and Time of Injury
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Describe the mechanism of injury (e.g., fall, explosion, impact)
*
Was there a loss of consciousness?
*
No
Yes, less than 1 minute
Yes, 1–5 minutes
Yes, more than 5 minutes
Symptoms observed (select all that apply)
*
Headache
Dizziness/Vertigo
Nausea/Vomiting
Confusion/Disorientation
Memory Loss
Loss of Balance
Visual Disturbance
Ringing in Ears
Other
Glasgow Coma Scale (GCS) Assessment
*
Rows
Eye Opening
Verbal Response
Motor Response
Score
4 - Spontaneous
3 - To voice
2 - To pain
1 - None
5 - Oriented
4 - Confused
3 - Inappropriate words
2 - Incomprehensible sounds
1 - None
6 - Obeys commands
5 - Localizes pain
4 - Withdraws to pain
3 - Flexion to pain
2 - Extension to pain
1 - None
Visible signs of injury (select all that apply)
*
Scalp Laceration
Swelling/Bruising
Bleeding from ears/nose
Pupillary Changes
None
Other
Immediate actions taken
*
Medical provider's name and rank
*
Date and time of evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Signature of Evaluator
*
Submit Evaluation
Submit Evaluation
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