Get Concussionmild Traumatic Brain Injury Intake Form - Oregon Providence

Filling out the Concussion/Mild Traumatic Brain Injury Intake Form is a crucial step in documenting your injury and receiving appropriate care. This guide provides clear and detailed instructions for users to help them complete the form online accurately and efficiently.

Follow the steps to fill out the form effectively

1. Use the ‘Get Form’ button to access the form and open it in an editor.
2. Begin by providing your name, date, and age at the top of the form.
3. Fill in the date and time of your injury, along with a brief description of the incident.
4. Indicate the location of the impact on your head by selecting one of the specified areas or writing in another location if applicable.
5. Specify the cause of the injury, choosing from options such as car accident, fall, or sports.
6. Answer the questions regarding your memory before and after the injury, and indicate whether you lost consciousness.
7. Report any early signs you experienced following the injury, such as feeling dazed or confused.
8. Indicate if you received medical attention immediately after the injury and provide details about any tests performed.
9. Check any symptoms you have experienced since the injury, such as headaches, dizziness, or sensitivity to light.
10. Answer questions about your medical history, including any previous instances of similar symptoms or conditions.
11. Provide information about how you learn best and whether your symptoms worsen with exertion or concentration.
12. Rate your average pain or symptoms and your proximity to normal function on a scale from 0 to 10.
13. Discuss skills or abilities you hope to regain through therapy.
14. List any over-the-counter or prescription medications you are currently taking.
15. Complete the medical and social history sections, noting any known allergies and your support system.
16. Finalize any additional information requested and review the form for completeness.
17. Once you have filled in all required fields, save your changes, download, print, or share the completed form as needed.

Complete your Concussion/Mild Traumatic Brain Injury Intake Form online today for timely evaluation and support.