Online TBI Questionnaire

As a veteran seeking an appointment with Dr. Kohn, we ask that you fill out the following Online TBI Questionnaire as best you can. On the form, check the symptoms that apply to you since the date of your injury.

You will also need to:

Complete the Veteran TBI New Patient Form
Send a copy of your DD214 and current medication list to our office.

Online TBI Questionnaire

Patient Name

Email

COGNITIVE

Attention/Distraction

Short Term MEMORY

Planning/Organization

ORIENTATION

Loss of sense of time... day, date, month, year

Loss of sense of Situation, what you are suppose to be doing

Loss of sense of Place, where you are now

Loss of identity, who you are

SOCIAL INTERACTION

Inappropriate Behavior at Home

Inappropriate Behavior at Work

Inappropriate Behavior while Driving

SOCIAL INTERACTION SYMPTOM SEVERITY

Mild

Moderate

Severely Appropriate

MOTOR SKILLS

Loss or difficulty performing previously learned skills

Loss or difficulty correctly completing a sequence of steps; getting dressed, using a tool, hitting a golf ball, throwing a baseball, kicking a soccer ball, etc

JUDGEMENT

Decision-making difficulties

Difficulty estimating consequences of choices

Poorly thought-out decision resulting in problems

Poor decision making in social settings; home, work, friends

POOR DECISION MAKING IN SOCIAL SYMPTOMS OCCURRED:

At Home

At Work

While Driving

COMMUNICATION

Changes in understanding conversation

Changes in understanding reading

Changes in writing ability, word choice, sentences, etc.

Changes in speaking ability, word choice, reversing letters

Changes in number ability, reversing numbers heard or written

Loss of skills of communication

Thanks for submitting!

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