Traumatic Brain Injury Checklist
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Please rate the student's behavior (in comparison to same-age classmates) using the following rating scale:
| Problem | Not At All | Occasionally | Often | Very Severe & Frequent Problem |
|---|---|---|---|---|
| A. Orientation and Attention to Activity | ||||
| Confused with time (day, date); place (classroom, bathroom, schedule changes); and personal information (birth date, address, phone, schedule) | ||||
| Seems "in a fog" or confused | ||||
| Stares blankly | ||||
| Appears sleepy or to fatigue easily | ||||
| Fails to finish things started | ||||
| Cannot concentrate or pay attention | ||||
| Daydreams or gets lost in thoughts | ||||
| Inattentive, easily distracted | ||||
| B. Starting, Changing, and Maintaining Activities | ||||
| Confused or requires prompts about where, how or when to begin assignment | ||||
| Does not know how to initiate or maintain conversation (walks away, etc.) | ||||
| Confused or agitated when moving from one activity, place, or group to another | ||||
| Stops midtask (math problem, worksheets, story, or conversation) | ||||
| Unable to stop (perseverates on) inappropriate strategies, topics, or behaviors | ||||
| Gives up quickly on challenging tasks | ||||
| C. Taking in and Retaining Information | ||||
| Forgets things that happened even the same day | ||||
| Problems learning new concepts, facts, or information | ||||
| Cannot remember simple instructions or rules | ||||
| Forgets classroom materials, assignments, and deadlines | ||||
| Forgets information learned from day to day (does well on quizzes, but fails tests covering several weeks of learning) | ||||
| D. Language Comprehension and Expression | ||||
| Confused with idioms ("climbing the walls") or slang | ||||
| Unable to recall word meaning or altered meaning (homonym or homographs) | ||||
| Unable to comprehend or breakdown instructions with request | ||||
| Difficulty understanding "Wh" questions | ||||
| Difficulty understanding complex or lengthy discussion | ||||
| Processes information at a slow pace | ||||
| Difficulty finding specific words (may describe but not label) | ||||
| Stammers or slurs words | ||||
| Difficulty fluently expressing ideas (speech disjointed, stops midsentence) | ||||
| E. Visual-Perceptual Processing | ||||
| Cannot track when reading, skips problems, or neglects a portion of a page of written material | ||||
| Orients body or materials in unusual positions when reading or writing | ||||
| Gets lost in halls and cannot follow maps or graphs | ||||
| Shows left-right confusion | ||||
| F. Visual-Motor Skills | ||||
| Difficulty copying information from board | ||||
| Difficulty with notetaking | ||||
| Difficulty with letter formation or spacing | ||||
| Slow, inefficient motor output | ||||
| Poor motor dexterity (cutting, drawing) | ||||
| G. Sequential Processing | ||||
| Difficulty with sequential steps of task (getting out materials, turning to page, starting an assignment) | ||||
| Confuses the sequence of events or other time-related concepts | ||||
| H. Problem-Solving, Reasoning, and Generalization | ||||
| Fails to consider alternatives when first attempt fails | ||||
| Does not use compensatory strategies (outlining or underlining) | ||||
| Problems understanding abstract concepts (color, emotions, math and science) | ||||
| Confusion with cause-effect relationships | ||||
| Unable to categorize (size, species) | ||||
| Problems making inferences or drawing conclusions | ||||
| Can state facts, but cannot integrate or synthesize information | ||||
| Difficulty applying what they know in different or new situations | ||||
| I. Organization and Planning Skills | ||||
| Difficulty breaking down complex tasks (term papers, projects) | ||||
| Problems organizing materials | ||||
| Problems distinguishing between important and unimportant information | ||||
| Difficulty making plans and setting goals | ||||
| Difficulty following through with and monitoring plans | ||||
| Sets unrealistic goals | ||||
| J. Impulse or Self-Control | ||||
| Blurts out in class | ||||
| Makes unrelated statements or responses | ||||
| Acts without thinking (leaves class, throws things, sets off alarms) | ||||
| Displays dangerous behavior (runs into street, plays with fire, drives unsafely) | ||||
| Disturbs other pupils | ||||
| Makes inappropriate or offensive remarks | ||||
| Shows compulsive habits (masturbation, nail biting, tapping) | ||||
| Hyperactive, out-of-seat behavior | ||||
| K. Social Adjustment and Awareness | ||||
| Acts immature for age | ||||
| Too dependent on adults | ||||
| Too bossy or submissive with peers | ||||
| Peculiar manners and mannerisms (stands too close, interrupts, unusually loud, poor hygiene) | ||||
| Fails to understand social humor | ||||
| Fails to correctly interpret nonverbal social cues | ||||
| Difficulty understanding the feelings and perspective of others | ||||
| Does not understand strengths, weaknesses and self presentation | ||||
| Does not know when help is required or how to get assistance | ||||
| Denies any problems or changes resulting from injury | ||||
| L. Emotional Adjustment | ||||
| Easily frustrated by tasks or if demands not immediately met | ||||
| Becomes argumentative, aggressive, or destructive with little provocation | ||||
| Cries or laughs too easily | ||||
| Feels worthless or inferior | ||||
| Withdrawn, does not get involved with others | ||||
| Becomes angry or defensive when confronted with changes resulting from injury | ||||
| Apathetic and disinterested in friends or activities | ||||
| Makes constant inappropriate sexual comments and gestures | ||||
| Unhappy or depressed affect | ||||
| Nervous, self-conscious, or anxious behavior | ||||
| M. Sensorimotor Skills | ||||
| Identified problems with smell, taste, touch, hearing or vision | ||||
| Problems discriminating sound or hearing against background noise | ||||
| Problems with visual acuity, blurring or tracking | ||||
| Problems with tactile sensitivity (e.g., cannot type or play an instrument without watching hands) | ||||
| Identified problems with oromotor (e.g., swallowing), fine motor or gross motor skills | ||||
| Poor sense of body in space (loses balance, negotiating obstacles) | ||||
| Motor paralysis or weakness of one or both sides | ||||
| Motor rigidity (limited range of motion), spasticity (contractions) and ataxia (erratic movements) circle one | ||||
| Impaired dexterity (cutting, writing) or hand tremors | ||||
| Difficulty with skilled motor activities (dressing, eating) | ||||