Traumatic Brain Injury Second-Level Evaluation Form
Please complete this form to assess key symptoms and functional impacts related to traumatic brain injury. All fields are required for a comprehensive evaluation.
Patient Full Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Level of Consciousness
*
Alert
Drowsy
Stuporous
Unresponsive
Cognitive Function (e.g., memory, attention)
*
No impairment
1
2
3
4
Severe impairment
5
1 is No impairment, 5 is Severe impairment
Physical Symptoms (e.g., headache, dizziness)
*
None
1
2
3
4
Severe
5
1 is None, 5 is Severe
Behavioral/Emotional Symptoms
*
None
1
2
3
4
Severe
5
1 is None, 5 is Severe
Motor Function (e.g., coordination, balance)
*
Normal
1
2
3
4
Severely impaired
5
1 is Normal, 5 is Severely impaired
Speech and Language Function
*
Normal
1
2
3
4
Severely impaired
5
1 is Normal, 5 is Severely impaired
Functional Independence
*
Independent
Requires minimal assistance
Requires moderate assistance
Dependent
Additional Comments or Observations
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