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Brain Injury
Screening
Questionnaire

Check off the symptoms that the patient is experiencing from this list. This will help us understand the patientā€™s condition and how to help them. It is important to be as thorough as possible when checking off symptoms and writing down notes in the space provided.

Changes After Damage
to the Frontal Lobe

*Check all that apply

Changes After Damage
to the Temporal Lobe

*Check all that apply

Changes After Damage
to the Occipital Lobe

*Check all that apply

Changes After Damage
to the Cerebellum

*Check all that apply

Changes After Damage
to the Parietal Lobe

*Check all that apply

Changes After Damage
to the Brain Stem

*Check all that apply

Additional Notes

Please be as detailed as possible
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