Traumatic Brain Injury Intake Form

Please fill out the following form after you have scheduled

an appointment for your assessment 

After a head injury or accident, some people experience symtoms which can cause worry or nuisnace. We would like to know if you now suffer from any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one, please circle the number cloest to your answer.
Compared with before the accident, do you now (i.e. over the last 24 hours) suffer from:

Thanks for submitting!