Protocol - History of Head Trauma

I would like to ask you about injuries to your head or neck that you may have had at anytime in your life. Interviewer instruction: Record cause and any details provided spontaneously in the box at the bottom of the page. DO NOT query further about LOC or other details at this stage.

1. Have you ever been hospitalized or treated in an emergency room following an injury to your head or neck? Think about any childhood injuries you remember or were told about.

[ ] Yes - Record cause(s) in table below

[ ] No

2. Have you ever injured your head or neck in a car accident or from some other moving vehicle accident (e.g. motorcycle, ATV)?

[ ] Yes - Record cause(s) in table below

[ ] No

3. Have you ever injured your head or neck in a fall or from being hit by something (e.g. falling from a bike, horse, or rollerblades, falling on ice, being hit by a rock)? Have you ever injured your head or neck playing sports or on the playground?

[ ] Yes - Record cause(s) in table below

[ ] No

4. Have you ever injured your head or neck in a fight, from being hit by someone, or from being shaken violently? Have you ever been shot in the head?

[ ] Yes - Record cause(s) in table below

[ ] No

5. Have you ever been nearby when an explosion or a blast occurred? If you served in the military, think about any combat- or training-related incidents.

[ ] Yes - Record cause(s) in table below

[ ] No

6. If all above are "no" then proceed to question 7. If answered "yes" to any of the questions above, ask the following for each injury: Were you knocked out or did you lose consciousness (LOC)? If yes, how long? If no, were you dazed or did you have a gap in your memory from the injury? How old were you? (age is only needed if there was LOC)

If more injuries with LOC:

How many more? ___

Longest knocked out?___

How many ≥ 30 mins.?___

Youngest age? ___

7. Have you ever lost consciousness from a drug overdose or being choked?

____# overdose
____# choked

SCORING

______ # TBI-LOC (number of TBIs with loss of consciousness from #6a)

______ # TBI-LOC ≥ 30 (number of TBIs with loss of consciousness ≥ 30 minutes from #6a)

______ age at first TBI-LOC (youngest age from #6a)

_____ TBI-LOC before age 15 (if youngest age from #7B < 15 then =1, if ≥ 15 then = 0)

_____ Worst Injury (1-5):

If responses to #1-5 are "no" classify as 1 "improbable TBI".

If in response to #6a and 6b reports never having LOC, being dazed or having memory lapses classify as 1 "improbable TBI".

If in response to #6b reports being dazed or having a memory lapse classify as 2 "possible TBI".

If in response to #6a loss of consciousness (LOC) does not exceed 30 minutes for any injury classify as 3 "mild TBI".

If in response to #6a LOC for any one injury is between 30 minutes and 24 hours classify as 4 "moderate TBI".

If in response to #6a LOC for any one injury exceeds 24 hours classify as 5 "severe TBI".

_______ # anoxic injuries (sum of incidents reported in #7)

This protocol was adapted with permission from the Ohio State University TBI Identification Method

© reserved 2007, The Ohio Valley Center for Brain Injury Prevention and Rehabilitation