Head Trauma Case History

Head Trauma Case History

Head Trauma Case History

Head Trauma Case History

Head Trauma Case History

Head Trauma Case History

Type of Accident

Motor Vehicle

Where were you sitting?

Which restraints were used? (Check all that apply)

Did your vehicle hit another object?
Did other vehicle hit your vehicle?
Where was your vehicle hit?
Did you experience whiplash?
Did you hit your head?
Head Injury Description
What part of your head was affected?
Were you unconscious?
Initial Care
Did you see a doctor concerning the accident?
Did you see a doctor concerning the accident?
Subsequent/Other Professional Care
What kind of professional care for your injuries/trauma have you received or are you receiving?
Symptoms immediately following the accident
Difficulties Following Accident
Other Information
Subsequent Symptoms/Experiences​​​​​​​


Please consider each symptom and check in all the items that apply. Place check under MIN if the symptom is only minimally present or MAX if the symptom is very significant.

Blurred Vision, Distance Viewing was present before the accident
Blurred Vision, Distance Viewing had before the accident and worsened
Blurred Vision, Distance Viewing is new symptom since accident
Blurred Vision, Near Viewing was present before the accident
Blurred Vision, Near Viewing had before the accident and worsened
Blurred Vision, Near Viewing is new symptom since accident
Slow to shift focus, near to far to near was present before the accident
Slow to shift focus, near to far to near had before the accident and worsened
Slow to shift focus, near to far to near is new symptom since accident
Difficulty taking notes was present before the accident
Difficulty taking notes had before the accident and worsened
Difficulty taking notes is new symptom since accident
Putting or tugging sensation around eyes was present before the accident
Putting or tugging sensation around eyes had before the accident and worsened
Putting or tugging sensation around eyes is new symptom since accident
Difficulty moving or turning eyes was present before the accident
Difficulty moving or turning eyes had before the accident and worsened
Difficulty moving or turning eyes is new symptom since accident
Pain with movement of the eyes was present before the accident
Pain with movement of the eyes had before the accident and worsened
Pain with movement of the eyes is new symptom since accident
Wandering eye was present before the accident
Wandering eye had before the accident and worsened
Wandering eye is new symptom since accident
Double Vision was present before the accident
Double Vision had before the accident and worsened
Double Vision is new symptom since accident
Loss of place while reading was present before the accident
Loss of place while reading had before the accident and worsened
Loss of place while reading is new symptom since accident
Discomfort while reading was present before the accident
Discomfort while reading had before the accident and worsened
Discomfort while reading is new symptom since accident
Unable to sustain near work/reading for adequate periods was present before the accident
Unable to sustain near work/reading for adequate periods had before the accident and worsened
Unable to sustain near work/reading for adequate periods is new symptom since accident
General fatigue while reading was present before the accident
General fatigue while reading had before the accident and worsened
General fatigue while reading is new symptom since accident
Eyes get tired while reading before accident
Eyes get tired while reading had before the accident and worsened
Eyes get tired while reading is new symptom since accident
Headaches before accident
Headaches had before the accident and worsened
Headache is new symptom since accident
Pain in or around eyes before accident
Pain in or around eyes had before the accident and worsened
Pain in or around eyes is new symptom since accident
Easily distracted before accident
Easily distracted before the accident and worsened
Easily distracted is new symptom since accident
Decreased attention span before accident
Decreased attention span before the accident and worsened
Decreased attention span is new symptom since accident
Reduced concentration ability before accident
Reduced concentration ability before the accident and worsened
Reduced concentration ability is new symptom since accident
Reduced concentration ability is new symptom since accident
Difficulty remembering what has been read before accident
Difficulty remembering what has been read before the accident and worsened
Difficulty remembering what has been read is new symptom since accident
Difficulty remembering names of objects before accident
Difficulty remembering names of objects before the accident and worsened
Difficulty remembering names of objects is new symptom since accident
Difficulty remembering people's names before accident
Difficulty remembering people's names before the accident and worsened
Difficulty remembering people's names is new symptom since accident
Difficulty recalling information known in the past before accident
Difficulty recalling information known in the past before the accident and worsened
Difficulty recalling information known in the past is new symptom since accident
Difficulty recognizing formerly familiar objects before accident
Difficulty recognizing formerly familiar objects before the accident and worsened
Difficulty recognizing formerly familiar objects is new symptom since accident
Difficulty recognizing formerly familiar people before accident
Difficulty recognizing formerly familiar people before the accident and worsened
Difficulty recognizing formerly familiar people is new symptom since accident
Difficulty remembering things heard before accident
Difficulty remembering things heard before the accident and worsened
Difficulty remembering things heard is new symptom since accident
Difficulty remembering things seen before accident
Difficulty remembering things seen before the accident and worsened
Difficulty remembering things seen is new symptom since accident
Dizziness before accident
Dizziness before the accident and worsened
Dizziness is new symptom since accident
Poor coordination before accident
Poor coordination before the accident and worsened
Poor coordination is new symptom since accident
Clumsiness before accident
Clumsiness before the accident and worsened
Clumsiness is new symptom since accident
Loss of balance before accident
Loss of balance before the accident and worsened
Loss of balance is new symptom since accident
Poor eye-hand coordination before accident
Poor eye-hand coordination before the accident and worsened
Poor eye-hand coordination is new symptom since accident
Poor handwriting before accident
Poor handwriting before the accident and worsened
Poor handwriting is new symptom since accident
Poor posture before accident
Poor posture before the accident and worsened
Poor posture is new symptom since accident
Head tilt before accident
Head tilt before the accident and worsened
Head tilt is new symptom since accident
Face turn before accident
Face turn before the accident and worsened
Face turn is new symptom since accident
Covering, closing one eye before accident
Covering, closing one eye before the accident and worsened
Covering, closing one eye is new symptom since accident
Disorientation before accident
Disorientation before the accident and worsened
Disorientation is new symptom since accident
Get lost often before accident
Get lost often before the accident and worsened
Get lost often is new symptom since accident
Bothered by movement around you before accident
Bothered by movement around you before the accident and worsened
Bothered by movement around you is new symptom since accident
Bothered by noises around you before accident
Bothered by noises around you before the accident and worsened
Bothered by noises around you is new symptom since accident
Bothered by being touched before accident
Bothered by being touched before the accident and worsened
Bothered by being touched is new symptom since accident

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