![]() Trouble sleeping? Poor appetite or binge eating? Craving stimulant foods?.Do family and friends comment on changes in your behavior? Are people living around you on the outskirts of you?.Do you have feelings of anxiety, jumpiness, or nervousness?.Do you feel depressed? Are you fearful? Have you lost hope? Are you tired of fighting for recovery? Just want your life back the way it was?.Do you have difficulty handling your anger?.Have you noticed frequent mood swings or emotional outbursts?.Are you unintentionally repeating yourself in conversation?.Are you checking and rechecking your work? Does the slightest disruption in your routine derail you?.Are you able to anticipate the consequences of your actions? Can you foresee outcomes or project the future of a task.Do you have difficulty changing from one task to another?.Do you have difficulty monitoring and correcting your errors?.Do you have difficulty starting new tasks? Does a new task trigger depression, hopelessness or fatigue? Do you struggle to get in the mood to begin?.Do you have problems setting goals and priorities and keeping to your plan?.Do you have difficulty following through with planning for work or leisure activities? Do you accurately gauge the time a task will take?.Do your eyes struggle to track written text or follow moving objects?.Do you feel dizzy or nauseous? Are you bumping into objects more than usual? Whacking your elbows, hitting your head, or stubbing your toes frequently?.Do you have difficulty focusing your eyes on objects?.When reading, do printed letters appear to change their shape or position on the page? Are you experiencing eye strain or headaches when reading?.Do objects seem closer or farther away than they actually are?.Do you have increased sensitivity to light, sound, shopping, party, or large meeting environments?.Are you pronouncing words correctly? Is your tongue twisting words around or relocating words inaccurately in a sentence?.Are you struggling to spell words? Do you reverse the letters?.Is it difficult conversing with others or staying in a conversation?.Do you have problems expressing yourself in writing?.Do you have difficulty thinking of the exact word or words you want to use?.Do you have difficulty following a conversation?.Have you become impulsive, making decisions or remarks without thinking them through? Unintentionally hurting someone’s feelings? Impulse shopping?.Are you easily distracted? When interrupted, do you struggle to find your place again or return to your task?.Is it stressful to read and answer this questionnaire?.Do you drift off in conversation, unable to recall what has been said?.Do you have difficulty making decisions? Or remembering what you decided?.Are you having difficulty staying focused when you are driving?.Do you have difficulty focusing your attention while reading or watching TV?.Do you have difficulty concentrating on more than one topic or task at a time?.Do you have difficulty concentrating in noisy or strongly lit environments?.Are you having trouble concentrating? Holding a thought?.Are you having difficulty remembering life details from the past?.Do you forget what you’ve read? Or the last TV or radio topic?.Do you forget where you parked your car? Or your current driving destination?.Do you forget what people tell you? Or what you have said to others?.Are you overly sensitive to light, sound, motion, or intense environments? Do you have dark spots before you eyes or blurred vision? Does it get worse with fatigue?.Are your neck and shoulders beginning to hurt? Tingling down your arms? Overall aching feeling? Overall pain upon waking in the morning?.Do you tire more easily, either mentally or physically? Does fatigue worsen with pressured thinking or emotional situations?.Do you have pain in the back of your head? Does it move forward? Are there moments of very sharp or stabbing pain that lasts for a few moments?.Do you have more headaches since your injury? Pain in the temples or forehead?.Rate your problems on the following scale: Never, Occasionally, Sometimes, Frequently, or Always. Note if it made a pre-existing issue worse. Remember to distinguish and notice if you had the problem or condition before the accident when evaluating if you have the condition presently. Please read this list and indicate any problems you may be having. What medications are you currently taking? Were you given a prescription for this event?.Were x-rays, MRI, or CT scan taken? SPECT scan?.Did you hit your head? Were you shaken, or did you experience a physical impact?.Have you been in an accident recently, say, within the last year?.When answering these questions, do so in light of how you are presently functioning. This questionnaire will help focus your symptom discovery for brain injury.
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