Brain Injury Solutions Symptom Screening Tool

Symptom Screening Tool

A preliminary screening designed to help identify individuals who may benefit from a comprehensive brain injury evaluation.
Did you experience a blow to the head, a fall, a motor vehicle collision, or another event that caused your head or body to move suddenly?
Are you currently experiencing symptoms such as headaches, dizziness, balance problems, vision changes, memory difficulties, poor concentration, sleep changes, or mood changes?
Based on your responses, you may not meet the initial screening criteria.

However, symptoms and circumstances can vary. Please contact Brain Injury Solutions if you have concerns or would like to discuss your situation with our team.

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
- Referring Doctor's Name (if applicable)
- Referring Doctor's Contact Information (if applicable)
Should be Empty:

Symptom Screening Tool