TBI History Form Name: First Last DOB: MM slash DD slash YYYY Age nowDate MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code SSNreferred by Current medications: Allergies: 1. Date of accident/trauma MM slash DD slash YYYY 3. Describe the accident/trauma Type of Accident3A. Motor VehicleType of vehicle you were in: If other vehicle(s) involved, list type(s) Where were you sitting? Front Seat Left Side Middle Back Seat Right Side Unusual Position Which restraints were used? (Check all that apply) Lap shoulder car seat booster seat air bag Speed of vehicle you were inSpeed of other object or vehicleDid your vehicle hit another object? Yes No Or did other vehicle hit your vehicle? Yes No Where was your vehicle hit? Head On Toward Front Drivers Side Rear Ended Toward Rear Passenger Side Did you experience whiplash? Yes No Did you hit your head? Yes No On what? 3B. Other AccidentsType (ex Home Industrial Fall Hit by Object ,etc.) Please describe: 3C. ToxicType (ex: medication related, drug abuse, poison, etc.) Please describe: 3D. AnoxicType (ex: drowning, C02, anesthesia, cord around neck, etc.) Please describe: 3E. VascularType (ex: stroke, aneurysm, hemorrhage, etc.) Please describe: 3F. Other:please explain Please describe: 4. Head Injury DescriptionWhat part of your head was affected? Forehead Right Side Top of head Back of Head Left Side Face Were you unconscious? Yes No For how long? Comments 5. Initial CareDid you see a doctor concerning the accident? Yes No Whom did you see? When? Where? What were you or your family told? Comments: 6. Subsequent/Other Professional CareWhat kind of professional care for your injuries/trauma have you received or are you receiving?Family Physician : Chiropractor : Neurologist : Neuropsychologist : Emergency Room Doctor : Occupational Therapist : Physical Therapist : Speech Therapist : Audiologist/Otolaryngologist : Psychologist : Physiatrist : Psychiatrist Optometrist : Ophthalmologist : Osteopath : Massage Therapist : Other : 7. Symptoms immediately following the accident Double Vision Headache Loss of Memory Blurred Vision Pain In or Around Eyes Vomiting Dizziness Restrictive Field of View Loss of Balance Disorientation Flashes of Light Restricted Motion Comments 8. Difficulties Following AccidentA. Work RelatedPlease describe: B. Hobbies/AvocationalPlease describe: C. Recreational/SocialPlease describe: D. OtherPlease describe: 9. Other InformationPlease take the time to share with us anything else that you feel is relevant:I authorize the release of medical and/or other information pertinent to my care to the insurance company in order for me to be reimbursed.SignatureDate MM slash DD slash YYYY 10. Subsequent Symptoms/ExperiencesPlease consider each symptom . Place check under MIN if the symptom is only minimally present or MAX if the symptom is very significant.Blurred Vision, Distance ViewingWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Blurred Vision, Near ViewingWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Slow to shift focus, near to far to nearWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Difficulty taking notesWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Putting or tugging sensation around eyesWas present before accident MIN MAX Had before accident and has worsened MIN MAX Was present before accident MIN MAX Difficulty moving or turning eyesWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Pain with movement of the eyesWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Wandering eyeWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Double VisionWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Loss of place while readingWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Discomfort while readingWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Unable to sustain near work/reading for adequate periodsWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX General fatigue while readingWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Eyes get tired while readingWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX HeadachesWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Pain in or around eyesWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Easily distractedWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Decreased attention spanWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Reduced concentration abilityWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Difficulty remembering what has been readWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Difficulty remembering names of objectsWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Difficulty remembering people's namesWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Difficulty recalling information known in the pastWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Difficulty recognizing formerly familiar objectsWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Difficulty recognizing formerly familiar peopleWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Difficulty remembering things heardWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Difficulty remembering things seenWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX DizzinessWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Poor coordinationWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX ClumsinessWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Loss of balanceWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Poor eye-hand coordinationWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Poor handwritingWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Poor postureWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Head tiltWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Face turnWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Covering, closing one eyeWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX DisorientationWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Get lost oftenWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Bothered by movement around youWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Bothered by noises around youWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Bothered by being touchedWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Abnormal general fatigueWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Reduced depth perceptionWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Light sensitivityWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Flashes of lightWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Floaters in field of viewWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Restricted field of visionWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX Tunnel visionWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX "Curtain" billowing into field of viewWas present before accident MIN MAX Had before accident and has worsened MIN MAX New symptom since accident MIN MAX
