| Persistent
Intellectual Impairments |
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record |
| Memory problems |
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| Difficulty concentrating |
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| Attention Difficulties |
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| Easily Distracted |
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| Misplacing or difficulty tracking things |
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| Difficulty making decisions |
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| Difficulty solving problems |
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| Difficulty understanding spoken instructions |
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| Difficulty understanding written instructions |
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| Difficulty finding words |
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| Difficulty communicating thoughts / feelings |
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| Unintentionally repeating the same remarks |
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| Unintentionally repeating same activities |
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| Stuttering or stammering |
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| Difficulties doing simple math |
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| Impaired abstraction or literalness |
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| Mental rigidity |
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| Deficits in processing information |
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| Deficits in sequencing information |
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| Difficulty executing or doing things |
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| Difficulty starting or initiating things |
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| Difficulty handling work requirements |
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| Difficulty handling school requirements |
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| Having to check and re-check what you do |
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| Disoriented by slight changes in daily routine |
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| Unsure about things that you know well |
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| Difficulty learning new things |
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| Doing things slowly to insure correctness |
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| Decreased capacity for reality testing |
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| Impaired ability to appreciate details |
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| Impaired ability to benefit from experience |
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| Inappropriate responses to people & things |
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| Difficulty taking care of your self |
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| Difficulty taking care of children |
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| TOTALS |
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| Psychological
Consequences |
check |
score |
note |
| Impaired sense of self |
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| Fear of loss of control |
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| Easily agitated or irritated |
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| Easily startled |
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| Feelings of paranoia |
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| Spells of terror or panic |
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| Feelings of depression |
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| Feelings of shame or guilt |
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| Persistent anxiety |
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| Anxiousness or feelings of fear and dread |
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| Feelings of discouragement |
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| Withdrawal or social isolation |
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| Feeling others not appreciating your difficulties |
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| Feeling everything is an effort |
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| Feeling inept or worthless |
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| Laughing or crying without apparent cause |
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| Worrisome thoughts won't leave your mind |
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| Making up explanations for things |
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| Insensitive to others and social context |
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| Diminished insight |
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| TOTALS |
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| Persistent
Mood Disorders |
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score |
note |
| Mood swings |
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| Having urges to beat, injure or harm someone |
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| Shouting or throwing things |
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| Temper outbursts that you could not control |
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| TOTALS |
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| Persistent Physiological
Impairments |
check |
score |
note |
| Heart pounding or racing |
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| Rapid pulse |
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| Headaches or head pains |
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| Increased blood pressure |
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| Increased sensitivity to touch |
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| Ringing in ears |
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| Easily fatigued |
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| Numbness or tingling in parts of your body |
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| Weakness or loss of strength |
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| Feeling tense or keyed up |
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| Restlessness, unable to sit still |
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| Lessened ability to perform physically |
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| Decreased tolerance for alcohol and drugs |
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| Appetite disturbances |
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| Trouble falling asleep |
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| Awakening during the night |
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| Sleep that is restless or disturbed |
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| TOTALS |
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| Persistent
Personality Alterations |
check |
score |
note |
| Passivity, or submissiveness |
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| Aggressiveness |
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| Apathy, lack of interest or emotion |
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| Overly sensitive |
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| Discouragement or demoralization |
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| Increased emotional distress |
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| Chronic frustration |
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| Grandiosity or boastfulness |
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| Excessively talkative |
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| Compulsive writing |
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| Egocentricity |
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| Childishness |
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| Silliness |
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| Overly responsible |
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| Irresponsibility |
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| Impulsively |
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| Self-indulgent |
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| Indiscreet comments and acts |
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| Obscene comments or acts |
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| Increased sexual activity |
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| Decreased sexual activity |
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| Increased shame or guilt |
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| Religiosity |
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| TOTALS |
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| Persistent
Neurological Problems |
check |
score |
note |
| Sense of observing your self from afar |
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| Altered consciousness |
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| Slowed reaction time |
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| Smelling odors that others do not smell |
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| Hearing music that others do not hear |
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| Making up explanations for things |
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| Sensitivity to temperature shifts |
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| Seeing dark spots before your eyes |
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| Blurred vision, especially when fatigued |
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| Double vision especially when fatigued |
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| Diminished night vision |
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| Difficulty relaxing |
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| Twitching |
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| Sensitivity to sound or noise |
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| Sensitivity to light |
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| TOTALS |
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