Brain Injury Patient Questionnaire

Personal symptom discovery is key for the brain injury patient, according to Gail L. Denton in her book Brainlash.  Denton created a questionnaire, posted below, to assist patients in recognizing their symptoms in order to accurately address the problems that arise from the injury.  While reading over the questions, try to determine if the problem is post or pre injury.  If the symptom or issue emerged following the injury, then rate each problem on the following scale: Never, Occasionally, Sometimes, Frequently, or Always.

Pain

1.  Do you have more headaches since your injury?  Is the pain in the temples or forehead?
2. Do you have pain in the back of your head?  Does it move forward?
3.  Do you tire more easily, either mentally or physically?  Does the fatigue worsen with pressured thinking or emotional situations?
4.  Are your neck and shoulders beginning to hurt?  Tingling down your arms?  Overall aching feeling?  Overall pain upon waking in the morning?
5.  Are you overly sensitive to light, sound, motion, or intense environments?  Do you have blurred vision?  Does it get worse with fatigue?

Memory

1.  Do you lose or misplace items?
2.  Do you forget what people tell you?  Or what you have said to others?
3.  Do you forget where you parked your car?  Or your current driving destination?
4. Do you forget what you've read?  Or the last TV or radio topic?
5.  Are you having difficulty remembering life details from the past?

Attention and Concentration

1.  Are you having trouble concentrating?  Holding a thought?
2. Do you have difficulty concentrating in noisy or strongly lit environments?
3.  Do you have difficulty concentrating on more than one topic or task at a time?
4. Do you have difficulty focusing your attention while reading or watching TV?
5.  Are you having difficulty staying focused when you are driving?
6.  Do you have difficulty making decisions?  Or remembering what you decided?
7.  Do you drift off in conversation, unable to recall what has been said?
8.  Are you easily distracted?  When interrupted, do you struggle to find your place again or return to your task?
9.  Is it stressful to read and answer this questionnaire?
10.  Have you become impulsive, making decisions or remarks without thinking them through?

Language and Communication

1.  Do you have difficulty following a conversation?
2. Do you have difficulty thinking of the exact word or words you want to use?
3.  Do you have problems expressing yourself in writing?
4.  Is it difficult conversing with others or staying in a conversation?
5. Are you struggling to spell words?  Do you reverse the letters?
6.  Are you pronouncing words correctly?

Visual Perception

1.  Do you have increased sensitivity to light, sound, shopping, party, or large meeting environments?
2.  Do objects seem closer or farther away than they actually are?
3.  When reading, do printed letters appear to change their shape or position on the page?  Are you experiencing eye strain or headaches while reading?
4.  Do you have difficulty focusing your eyes on objects?
5.  Do you feel dizzy or nauseous?  Are you bumping into objects more than usual?
6.  Do your eyes struggle to track written text or follow moving objects?

Executive Function

1.  Do you have difficulty following through with planning for work or leisure activities?  Do you accurately gauge the time a task will take?
2.  Do you have problems setting goals and priorities and keeping to your plan?
3.  Do you have difficulty starting new tasks?  Do you struggle to get in the mood to begin?
4.  Do you have difficulty changing from one task to another?
6.  Are you able to anticipate the consequences of your actions?
7.  Are you checking and rechecking your work?  Does the slightest disruption in your routine derail you?
8.  Are you unintentionally repeating yourself in conversation?

Emotional Function

1.  Have you noticed frequent mood swings or emotional outbursts?
2.  Do you have difficulty handling your anger?
3.  Do you feel depressed?  Are you fearful?  Have you lost hope?
4.  Do you have feelings of anxiety, jumpiness, or nervousness?
5.  Do family and friends comment on changes in your behavior?
6.  Do you have trouble sleeping or a poor appetite?
7.  Have you become gullible?  Easily distracted or unintentionally naive?
9.  Are you easily startled, agitated, or irritated?

Finances and Measurements

1.  Do you have difficulty easily performing simple addition and subtraction?
2.  Can you easily make change at the store?
3.  Do you struggle to balance your checkbook as accurately as before?
4. Do you remember to open your mail, sort it, and pay your bills on time?
5.  Can you follow a recipe easily, or comprehend and follow instructions to assemble or operate something?

Safety

1.  Do you forget to turn off the iron, stove, or other household appliances?
2.  Do you forget to lock the doors to your home?
3.  Do you forget important appointments?
4.  Has your tolerance for alcohol, caffeine, or drugs decreased?