Traumatic Brain Injury (TBI) Residuals Evaluation Questionnaire Form
Please complete this assessment to help evaluate the residual symptoms and functional impact following a traumatic brain injury. Answer each question based on your current experience.
How often do you experience headaches related to your TBI?
*
Never
Rarely
Sometimes
Often
Always
Rate the severity of your memory problems since your TBI.
*
1
2
3
4
5
How frequently do you experience dizziness or balance issues?
*
Never
Rarely
Sometimes
Often
Always
Indicate the extent to which TBI-related symptoms interfere with your daily activities.
*
Not at all
1
2
3
4
5
6
7
8
9
Severely
10
1 is Not at all, 10 is Severely
How would you rate your concentration since your TBI?
*
1
2
3
4
5
Select the duration of your most persistent TBI symptom.
*
Please Select
Less than 1 month
1-3 months
3-6 months
6-12 months
More than 1 year
Please indicate how frequently you experience the following symptoms:
*
Rows
Never
Rarely
Sometimes
Often
Always
Sensitivity to light
1
2
3
4
5
Sensitivity to noise
6
7
8
9
10
Sleep disturbances
11
12
13
14
15
Mood changes
16
17
18
19
20
How would you describe your ability to perform work or school tasks since your TBI?
*
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to perform
How would you rate your current mood and emotional well-being?
*
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
Briefly describe any other symptoms or difficulties you have experienced since your TBI.
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