TABLE 1.

Sample items from parts I, II, and III of the Brain Injury Screening Questionnaire

Part I
For each event listed, record the number of times you experienced a blow to the head in that type of situation.		For each blow to the head recorded in Column A…
Column A		Column B
		Did you ever lose consciousness?		Were you ever dazed and confused?
Did you ever experience a blow to the head…	How many times?	How many times?	Longest period?	How many times?	Longest period?
In a car crash?
While on the playground?
Being assaulted or mugged?
Part II
Please check the boxes below to indicate how often, in the past month, you have been bothered by each of the difficulties listed.	Always	Often	Some- times	Never	N/A
Having double vision or blurred vision
Difficulty concentrating, having a poor span of attention
Doing things without thinking them through, being impulsive
Part III			Yes	No	Don't Know
Were you labelled as having a learning disability or an attention deficit disorder?
Were you ever medicated for a psychiatric condition?
Were you ever hospitalized or seen in the emergency room for a brain infection?

Abbreviation: N/A, not applicable.