Head Injury Assessment for TBI

1. Did you have any injury(ies) during your deployment from any of the following? (check all that apply):

• A. Fragment
• B. Bullet
• C. Vehicular (any type of vehicle, including airplane)
• D. Fall
• E. Blast (Improvised Explosive Device, RPG, Land mine, Grenade, etc.)
• F. Other

2. Did any injury received while you were deployed result in any of the following? (check all that apply in A-G or check H):

• A. Being dazed, confused or "seeing stars"
• B. Not remembering the injury
• C. Losing consciousness (knocked out) for less than a minute
• D. Losing consciousness for 1-20 minutes
• E. Losing consciousness for longer than 20 minutes
• F. Having any symptoms of concussion afterward (such as headache, dizziness, irritability, etc.)
• G. Head Injury
• H. None of the above

3. Are you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion? (check all that apply):

• A. Headaches
• B. Dizziness
• C. Memory problems
• D. Balance problems
• E. Ringing in the ears
• F. Irritability
• G. Sleep problems
• H. Other