Traumatic Brain Injury Questionnaire

Firm Name:*
Contact Name:*
Date:*
E-mail:*
Phone:*
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1). While on active duty, did your client experience any of these potential sources of head trauma listed below? Please check all that apply and designate the date(s) of occurrence(s), if possible:

A:
Vehicle Accident Date:
B:
Aircraft Crash Date:
C:
Blast Date:
D:
Wound Date:
E:
Fall Date:
F:
Strike Date:
G:
Athletic Injury Date:

2). For each item you endorsed, please answer the following questions that correspond to letter category of the accident type by selecting it and elaborating when appropriate:

Did you sustain any physical injuries to your face or head in any of the following?
If yes to any of above, briefly describe injuries to your head or face if possible:
Did you lose consciousness in any of the following?
If yes to any of above, briefly specify the duration of your unconsciousness using minutes, hours or days to describe it:
Did you have any amnesia for the time just prior to the trauma in any of the following?
If yes to any of above, briefly specify the duration of your amnesia prior to the trauma using minutes, hours or days to describe it:
Did you have any amnesia for the time immediately after the trauma in any of the following?
If yes to any of the above, indicate approximately how long this post trauma amnesia lasted using minutes, hours or days to describe:

3). Please answer the following questions about the injury/injuries described by selecting it and elaborating when appropriate:

Did the injury cause any short-term or long-term disablement in any of the following?
If yes to any of the above, briefly describe the disablement:
Did you receive or require acute medical attention from a medic or another provider in any of the following?
If yes to any of the above, indicate from whom and where you received this medical care:
Were you hospitalized for this injury after any of the following?
If yes to any of the above, indicate where and for how long you were hospitalized:
Did you receive long-term treatment or rehabilitation for any of the following?
If yes to any of the above, indicate where and for how long you received rehabilitation
Did you develop any symptoms such as headaches, dizziness, issues with concentration or memory, irritability, or a short fuse after from any of the following?
If yes to any of the above, list the major symptoms you had and how long each symptom lasted (or if you still have them):

3). Please check all that apply in regards to you your pre-service history, and designate the date(s) of occurrence(s), if possible:

H:
Physical Abuse Date:
I:
Substance Abuse Date:
J:
MVA Head Trauma Date:
K:
Fight Head Trauma Date:
L:
Other Accident Head Trauma Date:
M:
Pre-Service Athletic Injury
Did you lose consciousness in any of the following pre-service traumas?
If yes to any of above pre-service traumas, briefly specify the duration of your unconsciousness using minutes, hours or days to describe it:
Did the injury cause any short-term or long-term disablement in any of the following pre-service traumas?
If yes to any of above pre-service traumas, briefly describe the disablement:
Did you receive or require acute medical attention from a medic or another provider in any of the following pre-service traumas?
If yes to any of above pre-service traumas, indicate from whom and where you received it:
Were you hospitalized for this injury in any of the following pre-service traumas?
If yes to any of above pre-service traumas, where and for how long?
Did you develop any symptoms such as headaches, dizziness, issues with concentration or memory, irritability, or a short fuse after in any of the following pre-service traumas?
If yes to any of above pre-service traumas, If yes to any of the above, list the major symptoms you had and how long each symptom lasted (or if you still have them):
Word Verification:

This is strictly a data gathering tool intended for use by lawyers who represent wounded warriors. No treatment is implied or promised by its completion.