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Copyright © 1998 Head Injury Hotline
May not be altered nor copied without permission
Brain Injury Check List

From The Ashes:
A Brain Injury Survivor's Guide

Background: "Neuropsychological  impairments caused by brain injury may be characterized in terms of three functional systems (1) intellect which is the information-handling aspect of behavior;  (2) emotionality, which concerns feelings and motivations; and (3) control, which has to do with how behavior is expressed." 

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  "Brain damage rarely affects just one of these systems.  Rather, the disruptive effects of most brain injuries, regardless of their size or location, usually involve all three systems." 
  -- Source: Neuropsychological Assessment, 2nd  Ed., 1983, 
by Muriel D. Lezak


     Moreover, brain damage gets in the way of the ability to store, process, accumulate, and retrieve information.  It also interferes with the ability to control emotions, to benefit from experience, to learn new information, and to be sensitive to the emotional needs of others.


  "We are in the early stages of a transformation that will lead to the real practitioners of medicine  --being the lay person in the family, and  in the community--  and  we health professionals can be coaches and supporters of self-care."
  -- Tom Ferguson, MD
Founder of Medical Self Care Magazine;
Medical Editor of the Millennium Whole-health Catalogue;
Author of Health On-Line, Addison Wesley, 1996

About the Brain Injury Checklist

There is nothing magical about the Brain Injury Checklist -- it is simply a  self-assessment tool -- but a  very helpful one since it can be used to track and measure your impairments as well as your improvements over time. It can help you prepare for doctor visits by identifying neuropsychological difficulties that you wish to discuss with your doctor. Additionally, it can be used to track things that are not especially problematic, but you want to change in yourself. 

Important details to report concerning such problems include: when the problem began, or what caused you to notice it; what was going on at the time; what do you think may have brought it on; what did you do about it; what made it worse; what made it better; has it improved; has it remained the same; do you notice it all of the time, or is it intermittent, how much does it interfere with your ability to function. 

Everyone who decides to do something in this area basically wants things to be different (better) which means that in some way and to some degree the person is unhappy with him or herself, with life or with both. People can be roughly divided into those who experience emotional pain or upheaval with things the way they are and those who although not deeply unhappy or emotionally trapped have a desire for things to be better and for life to be more satisfying.

Developing an awareness of the problem is the first step in the process of change, the Brain Injury Checklist will increase your awareness of your neuropsychological impairments. The next step is to develop a plan that you will use as a road map for achieving your rehabilitation goals. Planning forms in subsequent sections of this site will provide additional guidance. 

The well crafted plan will include a description of  nature of the problem. Additionally, it should explore a few, well considered courses of action, along with your proposed destination, and what you intend to do to reach it. 

Brain Injury Check List

Below is a list of impairments that commonly result from brain injury. The number and type of items that you will check-off will depend on the type and scope of damage that you susstained. Some individuals will experience impairments that are spread over many sytems. While others will be limited to a few sytems. The Brain Injury Checklist was designed to prepare you to identify and track such impairments in yourself. The Brain Injury Checklist will help you to prepare for doctor visits by identifying problems or patterns that you wish to discuss with your doctor. Additionally, it can be used to track things that are not especially problematic, but you want to change in yourself. 

Important Note:  While the appearance of such symptoms can be worrisome, rest assured that they will get better over time.  You should notice progressive improvements especially if you actively work at getting better.  The forms in this section will help you increase your self awareness and help you chart your progress and set backs. 

     Non-credit, remedial course work in basic skills will help refresh your memory and  help restore you intellectual skills.  Telecourses can help you rebuild skills at your own pace in the privacy of your home.  Frequently, such telecourse are available from your public library, and can be ordered over the phone, and delivered to your home free of charge. 

    Working the brain in this way after a brain injury can involve a certain amount of discomfort, anxiety and dread.  Additionally, you might find that learning, thinking, or doing things takes more effort, and more energy than it did before your brain injury.  You might find that you feel overwhelming fatigue following any type of mental or physical exertion.  When such symptoms appear, don't despair, take a break, to refresh yourself and hit it again later. 

     This type of experience can be very discouraging, however, don't let it get you down, the rewards of such activities are well worth any negative emotions that you initially might feel.  Because you might be more susceptible to fatigue and depression, remember to pace yourself.   Be mindful of  your diet and water intake.  Hunger, thirst, and fatigue can tax your brain and cause your symptoms to worsen.   However appropriate rest and refreshment can restore your functioning. Use our Wellness Inventory to track your diet, exercise and water intake as erll as your feeling states.

Instructions:  The following is a partial list of neuropsychological impairments caused by brain injury. First, print this form.  Next, place a check mark beside each impairment that you noticed in your self in the past 24 hours.  Then, on a scale of  0 to 4 rate the effect of the impairment on you  during the past 24 hours.  For example:   0 = not present;  1 = minimal, present but does not interfere with activities;  2 = mild, some effect, interferes with activities but not disabling; 3 = moderate, greatly interferes with activities; and a score of 4 = extremely disabling, unable to function.

   Next, write down what you did about the impairments that you scored 2, 3 , or 4. For example, took a nap, practiced deep breathing or deep relaxation exercises;  stepped back from the situation to gain  perspective; confided in a trusted, knowledgeable friend or family member;  spoke with a health care professional, re-priortized or rearranged your schedule; scapegoated an innocent bystander; self medicated with drugs, alcohol, or other substances; acted on impulse. 

    Additionally, take note of what you were doing when you noticed your impairments.  For instance, you might have noticed them as you  were dealing an with especially stressful situation.  Then, at other times they might have gotten in the way of simple everyday obligations. 

   On some days you might experience a great number of the more troublesome impairments and find yourself totally dysfunctional as a result.  Then, on other days you might be symptom free, and highly functional. Such a pattern is a common feature of neuropsychological disorders due to brain injury. 

    This type of variation is all the more reason to utilize this check list to track and measure the impairments that are problematic for you.  If used properly,  it will increase your awareness of your difficulties as well as those things that make them better and those that make them worse.  In so doing you will become empowered to change your life for the better. 

(Review: "Check" each impairment that you noticed in the past 24-hours -- "Score" each impairment 0, 1, 2, 3, or 4; -- Then record what you did about it in the "note " column.)

Click here or scroll down to see Checklist 


Persistent Intellectual Impairments  check  score  note 
Memory problems      
Difficulty concentrating      
Attention Difficulties      
Easily Distracted      
Misplacing or difficulty tracking things      
Difficulty making decisions      
Difficulty solving problems      
Difficulty understanding spoken instructions      
Difficulty understanding written instructions      
Difficulty finding words      
Difficulty communicating thoughts / feelings      
Unintentionally repeating the same remarks      
Unintentionally repeating same activities      
Stuttering or stammering      
Difficulties doing simple math      
Impaired abstraction or literalness      
Mental rigidity      
Deficits in processing  information      
Deficits in sequencing information      
Difficulty executing or doing things      
Difficulty starting or initiating things      
Difficulty handling work requirements       
Difficulty handling  school requirements      
Having to check and re-check what you do      
Disoriented by slight changes in daily routine      
Unsure about things that you know well      
Difficulty learning new things      
Doing things slowly to insure correctness      
Decreased capacity for reality testing      
Impaired ability to appreciate details      
Impaired ability to benefit from experience      
Inappropriate responses to people & things      
Difficulty taking care of your self      
Difficulty taking care of children      
 TOTALS      
Psychological Consequences  check  score  note
Impaired sense of self      
Fear of loss of control      
Easily agitated or irritated      
Easily startled      
Feelings of paranoia      
Spells of terror or panic      
Feelings of depression      
Feelings of shame or guilt      
Persistent anxiety      
Anxiousness or feelings of fear and dread       
Feelings of discouragement      
Withdrawal or social isolation      
Feeling others not appreciating your difficulties      
Feeling everything is an effort      
Feeling inept or worthless      
Laughing or crying without apparent cause       
Worrisome thoughts  won't leave your mind      
Making up explanations for things      
Insensitive to others and social context      
Diminished insight      
 TOTALS      
Persistent Mood Disorders  check  score  note
Mood swings      
Having urges to beat, injure or harm someone      
Shouting or throwing things      
Temper outbursts that you could not control      
TOTALS      
Persistent Physiological Impairments  check  score  note
Heart pounding or racing      
Rapid pulse      
Headaches or head pains      
Increased blood pressure      
Increased sensitivity to touch      
Ringing in ears      
Easily fatigued      
Numbness or tingling in parts of your body      
Weakness or loss of strength      
Feeling tense or keyed up      
Restlessness, unable to sit still      
Lessened ability to perform physically      
Decreased tolerance for alcohol and drugs      
Appetite disturbances      
Trouble falling asleep      
Awakening during the night      
Sleep that is restless or disturbed      
TOTALS      
Persistent Personality Alterations  check  score  note
Passivity, or submissiveness      
Aggressiveness      
Apathy, lack of interest or emotion      
Overly sensitive      
Discouragement or demoralization      
Increased emotional distress      
Chronic frustration      
Grandiosity or boastfulness      
Excessively talkative      
Compulsive writing      
Egocentricity      
Childishness      
Silliness      
Overly responsible      
Irresponsibility      
Impulsively      
Self-indulgent      
Indiscreet comments and acts      
Obscene comments or acts      
Increased sexual activity      
Decreased sexual activity      
Increased shame or guilt      
Religiosity      
TOTALS      
Persistent Neurological Problems  check  score  note
Sense of  observing your self from afar      
Altered consciousness      
Slowed reaction time      
Smelling odors  that others do not smell      
Hearing music that others do not hear      
Making up explanations for things      
Sensitivity to temperature shifts      
Seeing dark spots before your eyes      
Blurred vision, especially when fatigued      
Double vision especially when fatigued      
Diminished night vision      
Difficulty relaxing      
Twitching      
Sensitivity to sound or noise      
Sensitivity to light      
TOTALS      



Copyright © 1998 Head Injury Hotline. 
May not be altered nor copied without permission.
Brain Injury Resource Center:  Providing Difficult to Find Information on Brain Injury Since 1985
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Copyright © 1998 Head Injury Hotline