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My Account
Coaching
Coaching Services
Caregivers & Supporters
Family Coaching
Coaching for Long COVID Brain Fog & Other Cognitive Issues
FAQs
About
Our Approach
The Rebuild Difference
Our Coaches— Jon Jassy
Resources
About TBI & Mild TBI
Articles
Books
Rebuild Coaching Blog
Mild Brain injury life coaching.
Schedule a free consultation
Brain Injury Effects Questionnaire
Name
*
First Name
Last Name
Email Address
*
When did you have your concussion/mild TBI?
*
You don’t have to do this, but would you feel comfortable sharing with me how you got your concussion/brain injury? Feel free to share as much detail as you would feel comfortable about sharing.
Do you currently notice experiencing (or do other people tell you that they think you experience) any of the following in yourself?
Check 'Yes', 'No' or 'Other People' for each item. (Answer 'Other People' only if other people say an item is true about you but it is not consistent with your own personal experience.)
1. Headaches, nausea, dizziness more than twice/month that were not present before your brain injury
*
Yes
No
Other People
2. Heightened sensitivity to light and/or sound
*
Yes
No
Other People
3. Poor sleep (i.e., less than 6-8 hours or more hours of poor quality sleep)
*
Yes
No
Other People
4. Problems with attention or concentration
*
Yes
No
Other People
5. Problems with short-term memory
*
Yes
No
Other People
6. Problems with long-term memory
*
Yes
No
Other People
7. Problems with learning new things
*
Yes
No
Other People
8. Get flooded more easily, especially when having to deal with two or more things at once
*
Yes
No
Other People
9. Problems keeping track of time
*
Yes
No
Other People
10. Problems finding the right word, accurately expressing what’s in your head, or feeling like there is a word or something you know that is on the tip of your tongue but you can’t think of it
*
Yes
No
Other People
11. Trouble transitioning from one thing to another
*
Yes
No
Other People
12. More problems dealing with unexpected events/surprises coming up than other people do
*
Yes
No
Other People
13. Slowed processing speed/information processing
*
Yes
No
Other People
14. Not as good at problem-solving as you used to be, especially with new situations or situations with multiple factors to consider
*
Yes
No
Other People
15. Organizational difficulties
*
Yes
No
Other People
16. Problems with planning
*
Yes
No
Other People
17. Problems with situating things within the Big Picture (i.e, you can’t see the forest for the trees)
*
Yes
No
Other People
18. Trouble making decisions
*
Yes
No
Other People
19. Sometimes feel like you’re in a fog
*
Yes
No
Other People
20. Experienced feeling disoriented or wandering somewhere for no reason that you can remember
*
Yes
No
Other People
21. Trouble getting started on things (even if you know it’s something you have to/should do)
*
Yes
No
Other People
22. Not as persistent as you were before your concussion/mild TBI
*
Yes
No
Other People
23. Problems with your filter, in what you say to other people
*
Yes
No
Other People
24. Do impulsive things/make poorly thought-out decisions
*
Yes
No
Other People
25. Get tired more easily (mentally or physically)
*
Yes
No
Other People
26. Anxiety threshold or anxiety tolerance is lower than it was before your concussion/mild TBI
*
Yes
No
Other People
27. Drink alcohol or use drugs that are not prescribed to you, at least once/week
*
Yes
No
Other People
28. Lower frustration tolerance, or more irritable or impatient than you used to be
*
Yes
No
Other People
29. When angry/impatient, lose your temper more easily, or ‘go from 0 to 60’ more quickly
*
Yes
No
Other People
30. Other people’s impressions of your challenges or behaviors are different from yours
*
Yes
No
Of the statements you answered 'yes' to, which are the 2 or 3 biggest challenges for you to deal with right now?
Thank you!
