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Head Injury Questionnaire
Confidentiality
Read Privacy Statement
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No
Privacy Statement
All information entered on this form is private and confidential. As a mental health service, we prioritise your privacy and the confidentiality of your personal and health information. The details you provide will only be used to support your care and treatment and will not be shared with any third parties without your explicit consent. Your trust is important to us, and we are committed to protecting your privacy in accordance with applicable privacy laws and professional standards.
Address & Contact
Your Full Name?
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PostCode?
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Email?
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GP Details
Practice?
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PostCode?
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Email? (if known)
Head Injury Questions?
Approx what year did you have your injury?
How did you obtain your head injury?
Select
Act of Violence
Anoxic/Hypoxic
Hereditary
Medical Procedure
Personal Injury
Road Traffic Accident
Sports Injury
Other
How did you obtain your head injury?
More Information?
What were the circumstances?
Physical symptoms?
Loss of consciousness
Persistent Headaches
Intermittent headaches
Nausea and vomiting
Fatigue or drowsiness
Sleep disturbances
Excessive sleeping
Dizziness or loss of balance
Blurred vision
Altered taste or smell
Tinnitus
Emotional and Behavioural Symptoms
Mood swings
Emotional instability
Depression
Feelings of sadness
Increased fear response
Irritability
Aggressive
Impulsivity
Decreased inhibition
Cognitive symptoms?
Memory loss or amnesia
Disorientation or confusion
Reduced concentration
Reduced attention span
Slowed thought processes
Impaired judgement
Impaired decision-making skills
Advanced or Severe Symptoms
Convulsions or seizures
Clear fluids leaking from the nose or ears
Weakness or numbness in fingers and toes
Loss of coordination
Profound confusion
Slurred speech
Conditions?
PTSD
Health Anxiety
Phobias
Dissociation
Additional Disabilities
Ataxia
Autism
Epilepsy
Spinal Injury
Limb Loss
Health
Mobility Device?
Not Needed
Crutches
Wheelchair User
Motorised Wheelchair
Supporting Frame
Other
Other
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
Other
Any Other Medical Issues?
Yes
No
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
Anything to add Medically?
If you are human, leave this field blank.
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