Head Injury Questionnaire

Client Injury Checklist

Injured Person: _____

DIRECTIONS: Since the date of the accident, have you experienced any of the following problems? Please place a check mark on the line that applies.

YES NO

___ ___ Dizziness/Loss of balance

___ ___ Blackouts/Seizures

___ ___ Blurred or Double vision

___ ___ Ringing in ears

___ ___ Weak muscles

___ ___ Numbness or tingling

___ ___ Being tired or having trouble sleeping

___ ___ Nausea

___ ___ Headaches

___ ___ Trouble hearing

___ ___ Can’t concentrate

___ ___ Difficulty paying attention

___ ___ Forgets appointments, name, phone numbers, etc

___ ___ Drives dangerously

___ ___ Gets lost

___ ___ Forgets where you are going or why you are going

___ ___ Misunderstands what others say

___ ___ Forgets to finish chores (eg. Leaves items on stove, etc)

___ ___ Gets bored easily

___ ___ Overreacts to events

___ ___ Gets mad or angry easily

___ ___ Frustrated

___ ___ Gets depressed

___ ___ Nervous or anxious

___ ___ Trouble remembering how to do things at work or home

___ ___ Has started using reminder notes or asking others for help

___ ___ Difficulty following directions

___ ___ Misunderstand what others mean

___ ___ Does inappropriate things in social settings

___ ___ Difficulty expressing thoughts verbally

___ ___ Acts inappropriately to others

___ ___ Difficulty on the job or at school

___ ___ Writing or reading has become more difficult

___ ___ Avoids family or friends

To what extent have the changes affected your life?

0–1–2–3–4–5–6–7–8–9–10

severely none moderate

Dated: ___

Completed by: ____

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