Head Injury History

First Name *

Last Name *

Your Email *

Have you received any special education? *
 Yes No

Have you been diagnosed with any learning disabilities? *
 Yes No

Have you been previously diagnosed with ADHD or ADD? *
 Yes No

Have you received any speech therapy? *
 Yes No

Number of times you have been diagnosed with a concussion. *
 0 1 2 3 4 >5

Number concussions that resulted in loss of consciousness. *
 0 1 2 3 4 >5

Number concussions that resulted in confusion. *
 0 1 2 3 4 >5

Number concussions that resulted in difficulty remembering events immediately after trauma. *
 0 1 2 3 4 >5

Number concussions that resulted in difficulty remembering events that occurred. *
 0 1 2 3 4 >5

Have you had any issues with ADHD? *
 Yes No

Have you been previously diagnosed with Dyslexia? *
 Yes No

Have you been previously diagnosed with a disorder on the Autistic spectrum? *
 Yes No

Any history of treatment for alcohol or drug addiction? *
 Yes No

Any history of treatment for mental health issues? *
 Yes No

Have you been previously treated for headaches or migraines? **
 Yes No

Have you been previously treated for seizures? *
 Yes No

Any history of meningitis? *
 Yes No

Any history of brain surgery? *
 Yes No

Have you played contact sports? *
 Yes No

Are you presently involved in contact sports? *
 Yes No

Please elaborate on any "Yes" notes above