Brain Injury Symptoms Checklist Arizona

Instructions: Complete all required fields marked with *. Check all symptoms you have experienced since your injury. When 5 or more post-incident symptoms are checked, strong consideration should be given to qEEG Brain Mapping.

Step 1

Patient Information

First Name*

Last Name*

Email Address*

Patient Cell Number*

Date of Birth*

Name of your attorney / law firm*

Name of your doctor / physician*

Who referred you to Neuron Connect?*

Section I

Mechanism of Injury

Check all that apply *

Motor vehicle collision with moderate damage or more than 17+ miles per hourNon-MVC involving quick or violent movements to the neck and/or body without contact with the headBlow to the headExposure to noxious chemicalsOxygen deprivationExposure to blast

Section II

Loss of Consciousness (LOC)

Did the injury result in any documented LOC? *

0 symptoms selected

When 5 or more post-incident symptoms are checked, strong consideration should be given to qEEG Brain Mapping.

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Brain Injury Symptoms Checklist

Patient Information

Mechanism of Injury

Loss of Consciousness (LOC)

Post-Incident Symptoms by Brain Region

Frontal Lobe

Parietal Lobe

Cerebellum

Brain Stem

Peripheral Vestibular

Temporal Lobe

Occipital Lobe

Localized Damage