Symptoms - hbtinstitute.com

1 I am sleepy, tired during day or doze off easilyUpset stomach, nausea, heartburn or vomitingDifficulty concentrating, mind wanders easilyI get overwhelmed easilyMood swings, happy one moment then sadAgitation (can t sit still, need to move around)Sadness, tearful episodes, crying easilyBlurry vision, had to get or change glassesAsking people to repeat things or hearing problemI make wrong turns driving or can t remember timeI get confused easily or cannot multi-task anymoreI have difficulty finding some words when talkingBright lights bother meI cannot pay attention as long as beforeI am eating more or less than normalRoom spins, lightheaded or woozy feelingBalance problemsI feel like my head is Foggy I have forgotten computer passwords or ATM PINI have to re-read things to understand what I readMy thinking is slowed downDifficulty with adding/subtracting numbersFear I will never be the same againDifficulty learning new thingsDifficulty understanding what people say to meDifficulty remembering or memory problemsCannot take on any more responsibilityI can t make decisions as quickly as beforeLoss of libido or lack of sexual desireI do not feel as confident of my abilitiesI get panic attacks, fast heartbeat.

2 NervousI am more irritable than usualSome food or drink tastes Funny to me nowI get frustrated very easilyDifficulty planning my life or organizing my workFlashbacks or frightening thoughts about accidentI have had bad dreams about the accidentI avoid places & objects that remind me about itI feel emotionally numb-no interest in my hobbiesI m feeling strong guilt, worry or depressionI am having trouble remembering the accidentI am easily startled since the accident - jumpy I feel tense or on edge most of the timeI am having difficulty sleepingI get angry easily or even yell at people now Clunk sound with neck movementsNeck painUpper back painLow back painShoulder painUpper arm painElbow painForearm painWrist painHand painHip painUpper leg painKnee painLower leg painAnkle painFoot painJaw painClicking in JawPain when chewingFace painChest painStomach painBruise to _____Scrape/Cut to _____Other Symptom _____Other Symptom _____SymptomsPatient _____ Date _____ Date of Injury _____Please fill in all Symptoms you currently havebefore the you did not haveBrain/Neuropsych/MTBI/PTSD SymptomsOrthopedic &

3 Musculoskeletal SymptomsNumb/Tingling Arm / Hand LRNumb/Tingling Leg / FootLRWeakness Arm / HandLRWeakness Leg / FootLRStiffness or limited movement in joint(s)HeadachesMuscle spasms/sore musclesDizziness, lightheaded, woozy feelingVisual disturbances or vision changeSleep changes/disruption of patternsPain radiates from one place to anotherAnxiety or nervous when drivingIrregular Heartbeat or uneven pulseFeeling depressed about thingsI am taking the following medications _____Neurological SymptomsSymptoms Associated with InjuriesI prefer being alone now (not socializing)LeftRightLeftRightLeftRightL eftRightLeftRightLeftRightLeftRightLeftR ightLeftRightLeftRightLeftRightLeftRight Patient Signature _____ Dr. Signature _____I go to work but work in painI limit my work activitiesBending at work hurtsStooping at work hurtsSitting at work hurtsUsing the Computer at work hurtsPushing at work hurtsPulling at work hurtsKneeling at work hurtsI have lost status in my companyI have lost job securityI didn t get a promotionI don t enjoy work as much as beforeI doze off at workI take unpaid time off work to go to daydream at work more than beforeI feel tired at workI need medication to be able to work.

4 I take _____ mg of _____ at ____ amwhen my pain level gets to ____/10 and/or again at _____ pm when my pain gets to ____/10My house is not as clean nowMy yard is not as neat nowMy garden is not as productive nowI do yard work, but do it in painI cannot do my normal yard workI do house work, but do it in painI cannot do my normal house workDoing laundry hurts meI cannot do laundry nowWashing dishes hurts meI cannot wash dishes nowVacuuming hurts meI cannot vacuum nowCooking hurts meI cannot cook nowWashing the car hurts meI cannot wash my car_____I work in pain because I have bills to payI can t take time off because I would lose my jobI keep working so I don t lose status at companyMy business would fail if I took time offI believe in working even when I m in painI feel obligated to work even though I m in painMy business would lose money if I took time offMy work is not as good as it was before accidentMy boss reprimanded me for poor performanceI got a different job within the same companyI got a different job in another companyI make less

5 Money than before the accidentI cannot do the same work/job as before accidentI can t concentrate as well at workI take paid time off to go to make mistakes at work I didn t used toI hide my poor work performance from my bossI cannot take time off because I care for childrenI have _____ children ages _____I had to hire a paid housekeeperI asked someone for unpaid housekeeping helpI had to hire a paid gardenerI asked someone for unpaid yard work helpMowing the lawn hurts meI cannot mow the lawnTaking out the trash hurts meI cannot take out the trashI do not enjoy my gardening/yardwork like I used toI do not enjoy my housework like I used toGardening hurts meI cannot do my gardening at all since the accidentOthers living with me do my share of the work nowOthers living with me do my share of the yard workOthers living with me do my share of the gardening_____Duties Performed Under Duress at Work and HomePatient _____ Date _____ Date of Injury _____InitialUpdatePlease check all that apply to your of the accidentPlease check all that apply to your HOME/DOMESTIC of the accidentSignatureDateMy exercise was affected by this crashI go to the gym & work out in painI no longer go to the gym to work outI run but in painI no longer runI take walks & have pain while walkiingI no longer take walksI used to make income at sportsI have lost sports income since crashI am an amateur athleteI am a professional athlete_____My hobbies were affected by accidentHobby #1 _____I can t do hobby #1 anymoreI do hobby #1 but

6 In painI have lost money from not doing #1I didn t do hobby #1 for _____ weeksHobby #2 _____I can t do hobby #2 anymoreI do hobby #2 but in painI have lost money from not doing #2I didn t do hobby #2 for _____ weeksI have gained _____ pounds since the accidentI had to quit my _____ team after the accidentI had to quit my _____ team after the accidentI had to quit my _____ team after the accidentI had to quit my _____ team after the accidentI don t enjoy the sport of _____ anymoreI didn t enjoy the sport of _____ for ____ weeksI don t enjoy the sport of _____ anymoreI didn t enjoy the sport of _____ for ____ weeksI don t enjoy the sport of _____ anymoreI didn t enjoy the sport of _____ for ____ weeksI don t enjoy the sport of _____ anymoreI didn t enjoy the sport of _____ for ____ weeksHobby #3 _____I can t do hobby #3 anymoreI do hobby #3 but in painI have lost money from not doing #3I didn t do hobby #3 for _____ weeksHobby #4 _____I can t do hobby #4 anymoreI do hobby #4 but in painI have lost money from not doing #4I didn t do hobby #4 for _____ weeks_____Loss of Enjoyment of Sports, Hobbies, Travel, Daily Activities, & School (p.)

7 1 of 2)Patient _____ Date _____ Date of Injury _____InitialUpdatePlease check all that apply to your EXERCISE & SPORTS of the accidentPlease check all that apply to your HOBBY of the accidentPlease check all that apply to your TRAVEL of the accidentBusiness travel was affected by crashPleasure travel was affected by crashI hurt driving in my own carI am in too much pain to driveI hurt when a passenger in a carI am in too much pain to sit in a carI have anxiety when I m in a carI hurt when I m on an airplaneI am in too much pain to travel by planeTravel Plan #1 _____I did not go on travel plan #1I went, but did not enjoy #1 as muchI went and the accident had no effect on #1 Travel Plan #2 _____I did not go on travel plan #2I went, but did not enjoy #2 as muchI went and the accident had no effect on #2I missed time with my family/friends b/c can t travelRiding in a carOpening a jarLifting a pan when cookingClosing the trunk on my carOpening the garage doorUsing my home computerClimbing stairsGoing down stairsSexual activityTurning my head to left or rightHolding my head up all dayWatching TVI have pain sitting & doing nothingTalking on the phoneReadingWritingOpening doorsDrying with a towel after a bath or showerLife has become a chore just to do normal thingsIt is depressing to live like this_____Loss of Enjoyment of Sports, Hobbies, Travel, Daily Living, & School (p.

8 2 of 2)Patient _____ Date _____ Date of Injury _____InitialUpdatePlease check all the DAILY LIVING Activities that cause you of the accidentPlease check all that apply to your SCHOOL & EDUCATION of the accidentSchool was affected by the accidentI am a student at _____I am in the _____ year/gradeI wasfull timepart timeI am nowfull timepart timeI had to take fewer classes b/c of crashI missed _____ days of schoolI had to drop out of school b/c of crashMy grades are lower since the crashI have pain carrying my school booksI hurt sitting in class more than _____ minutesMy neck hurts when I look down to readI don t learn as quickly as before the crashI don t learn things as well as before the crashI have difficulty concentrating in classIt takes much longer to

9 Study/do my homework_____DressingPutting on pantsPutting on shoesTying my shoesPutting on shirtDrying my hairCombing my hairWashing my hairTaking a showerTaking a bathLeaning forwardLaying in bedSitting in my favorite chairSleepingGoing out with my friendsSitting in a restaurantShoppingDriving to/from workSitting in ChurchPlaying with my childrenCaring for my childrenBending at the waistSitting in a movie theaterExerciseEatingStoopingSquatting downKneelingBrushing my teethSignature of PatientDatePatient _____ Today s Date _____ Date of Injury: _____NeckUpper Back & TorsoLumbar, Lumbosacral, SI & PelvisBrain & MiscellaneousStrain of Muscle, Fascia & Tendon (MFT)Upper & Lower ExtremityC HBTI 2/16/2016 Thoracic Segmental Dysf. ( )Thoracolumbar Segmental Dysf.

10 ( )Costochondral Segmental Dysf. ( )Costovertebral Segmental Dysf. ( )Sternochondral Segmental Dysf. ( )Sternoclavicular Segmental Dysf. ( )Rib Cage Segmental Dysf. ( )Thoracic Sprain ( )Chest/Sternum Pain ( )Thoracic Disc Displacement ( )Thoracolumbar Disc Displacement ( )Thoracic Torn Ligaments w/ Laxity ( )Thor/Lumb Torn Ligaments w/ Laxity ( )Thor. Motion Segment Hypermobility ( )Thor. Tendon Injury/Enthesopathy ( )Thoracic Pain ( )Thoracic Muscle Pain ( )Ribs Sprain ( )Sternoclavicular Sprain.( )Thoracic. Disc w/ Radiculopathy ( )Thoracolumbar Disc w/ Radiculopathy ( )Brachial Plexopathy ( )Thoracic DJD/DDD ( )Thoracolumbar DJD/DDD ( )Lumbar Segmental Dysfunction ( )Lumbar Sprain ( )Lumbar Torn Ligaments w/ Laxity ( )Lumbar Motion Segment Hypermobility ( )Lumbar Tendon Enthesopathy ( )Lumbago ( )Lumbar Myalgia ( ) ( ) ( )Lumbar Nerve Root Injury ( )Lumbar Radiculopathy ( )Spondylolisthesis (Congenital) ( )Spondylolisthesis (Acquired-Traumatic) ( )SI Sprain ( )Coccyx Sprain ( )L5/S1 ( )SI Seg.