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TBI form
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14
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HIPAA
Compliance
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1
Date
*
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Today's date
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Date
Month
Day
Year
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2
Name
*
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Prefix
First Name
Middle Name
Last Name
Suffix
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3
Unique ID
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4
Date of Accident
*
This field is required.
-
Date
Day
Month
Year
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5
Describe the Accident
*
This field is required.
Motor vehicle
Work Related
Other
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6
Please describe how you injured your head
*
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Please describe in as much detail as possible
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7
Please check the symptoms that you have been suffering from since the Accident
Headaces
Neck pain
short attention span
Irritability
anxiety
Depressed mood
Loss of consciousness, daze confusion immediately after the accident or since then
Ringing in the ears
Increase sensitivity to light
Increase sensitivity to sound
urge to vomit
Blurred vision
Daytime fatigue and loss of stamina
Loss or diminished sense of taste or smell
Dizziness, loss of balance or unsteadiness
Clear fluids from the nose or ears
Slowness in thinking, speaking, acting, reading
Mood changes (for no reason)
Difficulty remembering, concentrating or making Decisions
Getting lost or easily confused
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8
Describe any other symptoms not listed above
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9
Do you suffer from any chronic medical condition
Hypertension
Asthma
Other
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10
Please tell us what medication you take, including over the counter ones
*
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11
Are you allergic to any medications
YES
NO
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12
If so please list them
*
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13
Do you smoke
YES
NO
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14
Do you drink alcohol
YES
NO
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15
Have you sustained physical injuries in any other accidents in the past involving your head or any other body parts
Head
Neck
Other
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16
Signature
*
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Clear
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