TBI Symptoms Assessment Form
Assess traumatic brain injury symptom patterns by rating symptom severity, onset, progression, and daily impact. This form is for general assessment only and is not presented as HIPAA compliant or suitable for collecting sensitive medical information.
Symptom Overview
Are you currently experiencing symptoms?
*
Yes
No
Unsure
When did the symptoms begin or were first noticed?
-
Month
-
Day
Year
Date
Reason for assessment
*
Overall symptom severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Symptom Details
Rate TBI-related symptoms
*
Rows
None
Mild
Moderate
Severe
Headache
1
2
3
4
Dizziness
5
6
7
8
Nausea/Vomiting
9
10
11
12
Confusion
13
14
15
16
Memory Problems
17
18
19
20
Sensitivity to Light
21
22
23
24
Sensitivity to Sound
25
26
27
28
Blurred Vision
29
30
31
32
Balance Problems
33
34
35
36
Sleep Changes
37
38
39
40
Symptoms are
*
Getting better
Staying the same
Getting worse
Functional Impact and Next Steps
How much do your symptoms affect daily activities, school/work, or concentration?
*
Not at all
1
2
3
4
5
6
7
8
9
Extremely
10
1 is Not at all, 10 is Extremely
Are you seeking urgent medical evaluation?
*
Now
Soon
Not yet
Additional notes or context
Review your responses and submit when complete.
Submit TBI Symptoms Assessment Form
Should be Empty: