TBIQ Questionnaire

Traumatic Brain Injury Questionnaire

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Contact Name:*
Date:*
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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:
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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:
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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):
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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
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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):
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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.

Brain Injury Consultants, Inc.

In his role as a Board Certified Neuropychologist (licensed in New York, California and Florida), Dr. Fisher provides expert consultation in civil and criminal matters that involve the brain and behavior. Through a well established series of diagnostic techniques, he is able to provide quantitative and qualitative data about the short and long-term impact of brain injuries and brain diseases on how people think, act and behave. This carefully distilled information is critical to establishing if someone has been damaged by a brain injury as well as for understanding the significance of the resulting damages. In criminal matters, the diagnostic data provided by Dr. Fisher may prove helpful in establishing competency, understanding motivations for criminal behavior, as well as for mitigation.

 

More Information

Curriculum Vitae:
Jerid M. Fisher's complete document is available here including:

  • Personal Data
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  • Volunteer Positions
  • Past Affiliations
  • Education
  • Awards and Honors
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  • Scholarly Activity - Selected Presentations
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Special Projects: Jerid M. Fisher's involvement in the community is quite extensive.  More information outlining his involvement in community and charitable organizations is available.  Read More.

A Special Testimonial

 

November 5, 1998

Dear Jerid,

I am writing this on behalf of my father, Richard Jeffrey, better known as Jeff. Back in 1981 he was in a car accident, broad sided by a drunk driver. I don’t remember the path that led him to you… or you to him, but you two found each other. He met with a group of head injured adults… your pioneer group they dubbed themselves. You of course were at the helm, letting them talk, cry, feel each other’s misery, and yes, each other’s joy.  I know how much my father looked forward to those meetings… I was there for one semester of college. You let me sit in on the meetings, watching, learning, and to my father’s amazement, listening. It was apparent to us all, from a family perspective, that my Dad received much from you and that group.

My dad suffered a brain aneurysm five weeks ago. As he’d done with any other obstacle in his life thus far, he struggled hard and put up one hell of a fight. My Dad lost that struggle one week ago. We lost a great man.

As I sat at his funeral, I thought about all that he’d overcome in his life. I thought about his truth, his dignity, and his strength. He always managed to move on and bring his family right along with him. He’d just moved to Florida with Mom, ready for a new stage in his life. At 62 he was poised to be another Florida retiree with white shorts, sandals and a big grin on his face.

Before he left for Florida, he sat in my kitchen and said that he was going to find Jerid. No one questioned why. We knew that he wanted to shake your hand before he left, and to let you know that he would never forget how you had helped him pull his life back together after the accident. Sad to say, he was unable to find you.

Consider this letter to be a handshake from a guy with a big grin. I’m honored to carry out his wishes. Please know that he carried his respect for you in his heart, and I know that he is smiling as I write this letter.

The family of Richard Jeffrey has heard this phrase for the last 17 years… ‘I don’t have to be perfect just because I’m head injured’… and for that, we thank you.

Sincerely,

Karen Temple