Head Injury Outcome Assessment (HIO)

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Patients can experience post-concussion symptoms for days, weeks, months or even years. Now that a number of months have passed since your brain concussion, we would like to know which symptoms you are still experiencing and how much they have changed your life. Please choose the correct number below.

1 = I am exactly the same before my injury
2 = I still have mild symptoms or this makes my life a little different than before
3 = I still have moderate symptoms or this makes my life a lot different than before
4 = I still have severe symptoms or this makes my life completely different than before

Today's Date: *

YYYY

Your Full Name: *

Date of Accident/Injury: *

YYYY

Signature (Initials) *

Anxiety, nervousness, tightness in my chest or sweaty palms *

None

Severe

Depression, crying, more emotional or don't want to get out of bed *

Wishing my life was over or not optimistic about my future *

Irritability or anger that causes relationship problems for me *

Difficult finding simple words when I am talking *

Difficulty concentrating, thinking slowly or thinking makes me tired *

Memory problems, forgetting things or I have to write things down *

I don't understand what people say to me unless I concentrate *

I don't understand what I read unless I fully concentrate *

Loud noise, noisy rooms or many voices makes my uncomfortable *

I feel behind all the time, never catch up or get overwhelmed easily *

I get no joy or happiness from my hobbies or sports activities *

My sleep is different than before my injury *

I am tired, have no energy or don't feel like doing anything *

I have physical pain so bad that it is depressing to me *

My life now is not as good as the life I had before my injury *

Difficulty participating in conversations with 2 or more people *

Would you like a referral to a specialist for help with your life? *

Yes

Required

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