Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *How many impacts has your head taken? *Hard enough hit that you felt dizzy, passed out, had a bruise, or was diagnosed with a concussionNumber of hard knocks *1-34-66 or moreMood Swings *Looking for frequency and intensity of mood swings. Rate yourself on a Scale of 1-10 with one being not very often and 10 being more than you remember. Scale of 1-10, which best describes you *1-3 . . . . . . That happens to me from time to time4-6 . . . . . . I need to really take a look at this7-10 . . . . . It's affecting my relationshipsTrouble Focusing and/or Hyperactivity *It's difficult to finish tasks or pick back up where you left off. You're always looking for something else to do. Rate yourself on a Scale of 1-10Scale of 1-10, which best describes you1-3 . . . . . . I'm noticing it happening4-6 . . . . . . It's beginning to impact my life7-10 . . . . . .Tired of this and being medicated or thinking about it.Personality Changes *You just don't enjoy the things you used to. Having trouble socializing and having interest in much. Sad when you never used to be. Scale of 1-10, which best describes you1-3 . . . . . . I'm sometimes feel this way4-6 . . . . . . Feel this way more than ever7-10. . . . . . Definitely my vocabularyEnergy Level *Do you feel tired all of the time and struggle to get out of bed? Is it hard to make it through a 7 hour work day? You just want to stay home and not be around others. Scale of 1-10, which best describes you1-3 . . . . . . I'm starting to feel that way more often4-6 . . . . . . Most days I feel this way7-10. . . . . . Get out of bed? Why?Problems with Repetitive or Unfiltered Behavior *Scale of 1-10 that best describes you1-3 . . . . . . . I've been noticing uncharacteristic behaviors lately4-6 . . . . . . . I just can't seem to let go of things like I used to7-10 . . . . . . My filters are totally brokenJust want your "old self" back *Scale of 1-10, which describes you bestI'm beginning to feel this wayFind myself saying that more everydayHave been thinking this for a long timeEmailSubmit
