Traumatic Brain Injury Checklist

Date *

MM

/

DD

/

YYYY

Worksheet completed by: *

Student Name: *

School *

A. ORIENTATION AND ATTENTION TO ACTIVITY *

Not at all

Occasionally

Often

Very Often

Confused with time (day of week or date), daily routine, and/or personal information (birthdate/age, address, phone schedule)

Seems to be "in a fog"

Stares blankly

Appears sleepy or is easily fatigued

Fails to finish things

Difficulty concentrating or paying attention

Daydreams or gets lost in thoughts

Inattentive, easily distracted

Comments:

B. STARTING, CHANGING AND MAINTAINING ACTIVITIES *

Not at all

Occasionally

Often

Very Often

Confused or requires prompts about where, how or when to begin assignment

Doesn't not know how to initiate or maintain conversation

Confused or agitated when moving from one activity, place, or group to another

Stops mid-task (math problem, worksheets, story, or conversation))

Perseverates on certain topics or behaviors

Gives up quickly on challenging tasks

Comments:

C. ABSORBING AND RETAINING INFORMATION *

Not at all

Occasionally

Often

Very Often

Forgets things that happened recently or on the same day

Problems with learning new concepts, facts, or information

Cannot remember simple instructions or rules

Forgets classroom materials, assignments, and deadlines

Forgets information learned from day to day (may do well on daily work, but performs poorly on tests covering several weeks of learning)

Comments:

D. LANGUAGE COMPREHENSION AND EXPRESSION *

Not at all

Occasionally

Often

Very Often

Confused with idioms ("climbing the walls") or slang

Unable to recall word meaning or altered meaning (homonyms or homographs)

Difficulty with understanding instructions and/or requesting help

Difficulty understanding complex or lengthy discussions

Processes information at a slow pace

Difficulty finding specific words (may describe but not label)

Stammers or slurs words

Difficulty fluently expressing ideas (speech disjointed, stops midsentence)

Not at all

Occasionally

Often

Very Often

Confused with idioms ("climbing the walls") or slang

Unable to recall word meaning or altered meaning (homonyms or homographs)

Difficulty with understanding instructions and/or requesting help

Difficulty understanding complex or lengthy discussions

Processes information at a slow pace

Difficulty finding specific words (may describe but not label)

Stammers or slurs words

Difficulty fluently expressing ideas (speech disjointed, stops midsentence)

Comments:

E. VISUAL-PERCEPTUAL PROCESSING *

Not at all

Occasionally

Often

Very Often

Cannot track when reading, skips problems, or neglects a portion of a page of written material

Orients body or materials in unusual positions when reading or writing

Gets lost in halls and cannot follow maps or graphs

Shows left-right confusion

Comments:

F. VISUAL-MOTOR SKILLS *

Not at all

Occasionally

Often

Very Often

Difficulty copying information from board

Difficulty with note-taking

Difficulty with letter formation or spacing

Slow, inefficient motor output

Poor motor dexterity (cutting, drawing)

Comments:

G. SEQUENTIAL PROCESSING *

Not at all

Occasionally

Often

Very Often

Difficulty with sequential steps of task (getting out materials, turning to a specific page, starting an assignment)

Confuses the sequence of events or other time-related concepts

Comments:

H. PROBLEM-SOLVING, REASONING, AND GENERALIZATION *

Not at all

Occasionally

Often

Very Often

Does not consider alternatives when first attempt fails

Does not use compensatory strategies

Has problems understanding abstract concepts (color, emotions, math and science)

Confusion with cause-effect relationships

Difficulty categorizing objects or concepts (size, species)

Problems making inferences or drawing conclusions

Can state facts, but cannot integrate or synthesize information

Difficulty applying already learned knowledge to new or different situations

Not at all

Occasionally

Often

Very Often

Does not consider alternatives when first attempt fails

Does not use compensatory strategies

Has problems understanding abstract concepts (color, emotions, math and science)

Confusion with cause-effect relationships

Difficulty categorizing objects or concepts (size, species)

Problems making inferences or drawing conclusions

Can state facts, but cannot integrate or synthesize information

Difficulty applying already learned knowledge to new or different situations

Comments:

I. ORGANIZATION AND PLANNING SKILLS *

Not at all

Occasionally

Often

Very Often

Difficulty breaking down complex tasks into more manageable chunks (projects)

Problems organizing materials

Problems distinguishing between important and less important information

Difficulty making plans and setting goals

Difficulty following through and monitoring plans

Sets unrealistic goals

Comments:

J. IMPULSE OR SELF-CONTROL *

Not at all

Occasionally

Often

Very Often

Blurts out in class

Makes unrelated statements or responses

Acts without thinking (leaves class, throws things, sets off alarms)

Displays dangerous behavior

Disturbs other students

Makes inappropriate or offensive remarks

Shows compulsive habits (nail biting, tapping)

Hyperactive behavior, difficulty sitting for typical periods of time

Comments:

K. SOCIAL ADJUSTMENT AND AWARENESS *

Not at all

Occasionally

Often

Very Often

Acts socially immature for age

Overly dependent on adults

Too bossy or submissive with peers

Peculiar manners/mannerisms (stands too close, interrupts, unusually loud)

Difficulty understanding social humor

Difficulty with interpreting nonverbal social cues

Difficulty understanding the feelings and perspective of others

Does not understand own strengths or needs

Does not know when help is required or how to get assistance

Denies any problems or changes resulting from TBI

Not at all

Occasionally

Often

Very Often

Acts socially immature for age

Overly dependent on adults

Too bossy or submissive with peers

Peculiar manners/mannerisms (stands too close, interrupts, unusually loud)

Difficulty understanding social humor

Difficulty with interpreting nonverbal social cues

Difficulty understanding the feelings and perspective of others

Does not understand own strengths or needs

Does not know when help is required or how to get assistance

Denies any problems or changes resulting from TBI

Comments:

L. EMOTIONAL ADJUSTMENT *

Not at all

Occasionally

Often

Very Often

Easily frustrated by tasks or if demands not immediately met

Becomes argumentative, aggressive, or destructive with little provocation

Cries or laughs too easily

Feels worthless or inferior

Withdrawn, does not get involved with others

Becomes angry or defensive when confronted with changes resulting from TBI

Apathetic and/or disinterested in friends or activities

Makes inappropriate sexual comments and gestures to others

Unhappy or depressed affect

Nervous, self-conscious , or anxious behavior

Not at all

Occasionally

Often

Very Often

Easily frustrated by tasks or if demands not immediately met

Becomes argumentative, aggressive, or destructive with little provocation

Cries or laughs too easily

Feels worthless or inferior

Withdrawn, does not get involved with others

Becomes angry or defensive when confronted with changes resulting from TBI

Apathetic and/or disinterested in friends or activities

Makes inappropriate sexual comments and gestures to others

Unhappy or depressed affect

Nervous, self-conscious , or anxious behavior

Comments:

M. SENSORIMOTOR SKILLS *

Not at all

Occasionally

Often

Very Often

Problems with smell, taste, touch, hearing and/or vision

Problems with visual acuity, blurring or tracking

Tactile hypersensitivity (dislikes certain textures or tactile experiences)

Problems with oral motor abilities (e.g., swallowing) or fine motor/gross motor skills

Poor sense of body in space (loses balance, difficulty negotiating around obstacles)

Motor paralysis or weakness on one or both sides

Motor rigidity (limited range of motion), spasticity (contractions) and/or ataxia (erratic movements)

Difficulty with self-care activities (dressing, eating)

Not at all

Occasionally

Often

Very Often

Problems with smell, taste, touch, hearing and/or vision

Problems with visual acuity, blurring or tracking

Tactile hypersensitivity (dislikes certain textures or tactile experiences)

Problems with oral motor abilities (e.g., swallowing) or fine motor/gross motor skills

Poor sense of body in space (loses balance, difficulty negotiating around obstacles)

Motor paralysis or weakness on one or both sides

Motor rigidity (limited range of motion), spasticity (contractions) and/or ataxia (erratic movements)

Difficulty with self-care activities (dressing, eating)

Comments:

Additional/General Comments About Student: