Head Injury Follow Up Questionnaire (HIF)
We would like to know if your brain concussion symptoms are improving, staying the same or getting worse. Please click the box for each symptom and tell us how you are doing.
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Today's Date: *
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Your Full Name: *
Date of Birth: *
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Date of Accident/Injury: *
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Signature (Initials): *
Anxiety, nervousness or worry *
Required
Depression, crying or more emotional *
Required
Irritable or getting angry easily *
Required
Difficulty finding simple words when talking *
Required
Difficulty concentrating or thinking slowly *
Required
Memory problems or forgetting things *
Required
Understanding what people say to me *
Required
Sleep disturbance or disruption of sleep patterns *
Required
Fatigue, tiring more easily or low energy *
Required
The overall level of my physical pain(s) *
Required
Feeling behind, never caught up or overwhelmed *
Required
Relationship with my partner or family *
Required
Ability to enjoy my hobbies or leisure activities *
Required
Ability to exercise or play sports I enjoy *
Required
The quality or quantity of how much work I can do *
Required
How much I enjoy life *
Required
Loud noises, noisy rooms or crowds bother me *
Required
Loud noises, noisy rooms or crowds bother me *
Required
Bright lights bother me or I have to wear sunglasses *
Required
Feeling like I want to socialize with friends or family *
Required
Is there anything you'd like to add about how you feel regarding your head injury?
Answer pertaining the above (other)
Would you like a referral to a specialist (mostly neurologist) to run advanced concussion testing? *
Required
Would you like a referral to a specialist for mental or emotional issues *
Required
Would you like a referral to a medical specialist for help with physical pain *
Required
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