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Download Traumatic Brain Injury Screening
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Concussion/Traumatic Brain Injury Screening Baseline Functioning: Teacher Form Student: _____________________________ Teacher’s Name: __________________________ School: _____________________________ Subject Taught: ________________________ Grade: ________ Today’s Date: ______________ DOB: __________________ Age: ______ How long have you known this student? ____________ Date of Injury: ________________ This form is intended to provide information about the student’s skills and functioning BEFORE their injury. Please answer the following questions based on the overall time you have known this student: Did the student exhibit difficulties with any of the following on a regular basis? Irritability Yes No Long-term memory Yes No Overly emotional/crying Yes No Headaches Yes No Anger Yes No Nausea/stomach problems Yes No Depression Yes No Dizziness Yes No Anxiety Yes No Clumsiness Yes No Mood swings Yes No Loss of balance/falling Yes No Verbal aggression Yes No Oversensitive to sound Yes No Physical aggression Yes No Oversensitive to light Yes No Interacting with peers Yes No Reading Yes No Interacting with adults Yes No Math Yes No Trouble staying awake Yes No Planning or organizing Yes No Focus/concentration Yes No Completing assignments Yes No Short-term memory Yes No Understanding directions Yes No Please estimate the following as compared to same-age peers: Reading skills: Well Below Average Below Average Average Above Average Well Above Average Math skills: Well Below Average Below Average Average Above Average Well Above Average Below Average Average Above Average Well Above Average Overall ability to learn: Well Below Average Comments: ___________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
