Comprehensive TBI Screening Assessment

Privacy Notice

HIPAA Privacy Information

Purpose of this Assessment: This Traumatic Brain Injury (TBI) screening tool is designed to evaluate symptoms and functional impacts that may be associated with brain injury. This is not a diagnostic tool but a screening assessment to help determine appropriate next steps.

How Your Information Will Be Used: The information you provide in this assessment is considered Protected Health Information (PHI) under HIPAA (Health Insurance Portability and Accountability Act). Your responses will be:

Reviewed by qualified healthcare professionals to determine appropriate recommendations
Stored securely in accordance with HIPAA regulations
Used only for the purpose of your healthcare evaluation and treatment planning
Not shared with unauthorized third parties

Local Processing: This assessment runs entirely within your web browser. Your data remains on your device until you choose to submit the assessment. No information is automatically transmitted over the internet.

Results Handling: Upon completion, your assessment results will be securely transmitted to our healthcare team. You will receive a confirmation message, and a qualified professional will contact you with next steps and recommendations.

Your Rights: You have the right to:

Request access to your health information
Request corrections to your health information
Request restrictions on how your information is used or disclosed
Receive a copy of this privacy notice

Questions or Concerns: If you have questions about this privacy notice or concerns about how your information is being handled, please contact our Privacy Officer at [Your Contact Information].

Pass code

I have read and understand the privacy notice and consent to the collection and use of my information as described above.

Patient Information

First Name

Last Name

Date of Birth

Biological Sex

Case ID (if applicable)

Injury History

Please indicate if you have experienced any of the following:

1. Have you ever experienced a blow to the head or been nearby when an explosion occurred?

No Yes, once Yes, multiple times

2. Have you ever lost consciousness after a head injury?

(Even briefly, like "seeing stars" or "getting your bell rung")

No Yes, for less than a minute Yes, for 1-30 minutes Yes, for more than 30 minutes

3. Have you ever experienced memory loss or amnesia around the time of a head injury?

No Yes, less than an hour Yes, several hours Yes, more than a day

4. Have you ever been hospitalized or received medical treatment for a head injury?

No Yes, emergency room only Yes, hospital stay less than 3 days Yes, hospital stay 3 days or more

5. When did your most recent head injury occur?

6. Briefly describe how the injury occurred:

Cognitive Symptoms

Rate the frequency of the following symptoms in the past 30 days:

Never Rarely Sometimes Often Very Often

Physical Symptoms

Rate the frequency of the following symptoms in the past 30 days:

Never Rarely Sometimes Often Very Often

Emotional Symptoms

Rate the frequency of the following symptoms in the past 30 days:

Never Rarely Sometimes Often Very Often

Activities of Daily Living

This section assesses how symptoms impact daily functioning. Rate each activity based on the level of difficulty experienced since the injury compared to before.

Rating Scale:

0 = No difficulty (same as before injury)
1 = Mild difficulty (can still perform independently)
2 = Moderate difficulty (requires extra effort/time)
3 = Severe difficulty (requires assistance)
4 = Unable to perform (completely dependent)

Activity	Level of Difficulty
Self-care (bathing, dressing, grooming)	0 1 2 3 4
Meal preparation and eating	0 1 2 3 4
Home management (cleaning, laundry, repairs)	0 1 2 3 4
Financial management (paying bills, banking)	0 1 2 3 4
Medication management	0 1 2 3 4

Instrumental Activities

Activity	Level of Difficulty
Work or school performance	0 1 2 3 4
Driving or operating vehicles	0 1 2 3 4
Using public transportation	0 1 2 3 4
Shopping independently	0 1 2 3 4
Completing forms or paperwork	0 1 2 3 4

Social Functioning

Activity	Level of Difficulty
Maintaining interpersonal relationships	0 1 2 3 4
Participating in social gatherings	0 1 2 3 4
Community involvement/participation	0 1 2 3 4
Engaging in leisure activities or hobbies	0 1 2 3 4
Fulfilling family roles and responsibilities	0 1 2 3 4

Environmental Challenges

Challenge	Level of Difficulty
Navigating unfamiliar environments	0 1 2 3 4
Functioning in loud or busy settings	0 1 2 3 4
Handling multiple stimuli simultaneously	0 1 2 3 4
Performing under time pressure	0 1 2 3 4
Adapting to changes in routine or plans	0 1 2 3 4

Pre-injury vs. Post-injury Comparison

Occupational Status

Pre-injury employment/school status:

Current employment/school status:

If working or studying, have responsibilities or accommodations changed since the injury?

Independence Level

Pre-injury level of independence:

Current level of independence:

Additional notes or observations: