Clear TBI Symptom Screening Tool

Clear TBI Symptom Screening Tool

A preliminary assessment designed to help identify individuals who may qualify for traumatic brain injury biomarker testing.
Did you experience a blow to the head, or an injury where your head or body was suddenly forced forward, backward, or side to side?
Did symptoms begin within 7 days?
Are you currently experiencing symptoms related to the injury?
Based on your responses, you may not currently qualify for biomarker testing.

Modified Rivermead Post-Concussion Questionnaire (RPQ)

The following questions relate to symptoms commonly experienced after a head injury. Please compare how you feel now to how you felt before the injury and select the option that best describes your symptoms over the last 24 hours.
0 = Not present

1 = Present before the injury, but no worse now

2 = New mild problem since the injury

3 = New moderate problem since the injury

4 = New severe problem since the injury
- Headaches
- Feelings of Dizziness
- Nausea and/or Vomiting
- Light Sensitivity
- Noise Sensitivity
- Blurred Vision
- Double Vision
- Forgetfulness / Poor Memory
- Poor Concentration
- Taking Longer to Think
- Restlessness
- Sleep Disturbance
- Irritability / Easily Angered
- Feeling Depressed or Tearful
- Feeling Frustrated or Impatient
- Fatigue / Tiring More Easily
- Total RPQ Score
- Physical Sensory Score
- Are you experiencing any other difficulties? Please describe:
- Date Injured:
  
  MonthDayYear
  Date
- Injury from:
  
  Other
- Name
  
  First NameLast Name
- Email
  example@example.com
- Date of Birth
  
  MonthDayYear
  Date
- Zip Code or State
- Doctor's Name (optional)
- Doctor's Email (optional)
  example@example.com
Should be Empty:

Modified Rivermead Post-Concussion Questionnaire (RPQ)