North Carolina Symptom Questionnaire

Please use the paper copy provided to you by your client to complete the form below. Once this form is completed, scores will be calculated, and you will receive an email with follow up strategies and interventions to be used for addressing areas of concern. This information will be emailed to you by the Brain Injury Association of North Carolina.

MM slash DD slash YYYY
Name of Person Completing this Form on Behalf of the Client(Required)
Type of Agency

In recent weeks, how much have you been affected by the following problems? Please allow 30-45 minutes to answer this questionnaire.

MEMORY CONCERNS

I lose or misplace important items (keys, wallet, papers)(Required)
I forget what people tell me(Required)
I forget what I've read(Required)
I lose track of time(Required)
I forget what I did yesterday(Required)
I forget things I've just learned(Required)
I forget meetings and appointments(Required)
I forget to turn off appliances (iron, stove)(Required)

DELAYED PROCESSING

I have a hard time following conversations(Required)
I can remember only one or two steps of instructions or directions(Required)
I take too long figuring out what someone is trying to tell me(Required)

ATTENTION PROBLEMS

I have a hard time concentrating(Required)
I am easily distracted(Required)
I have a hard time concentrating in noisy places(Required)
I have a hard time following conversations(Required)
I have a hard time concentrating on challenging tasks (for example: work or paying bills)(Required)

INHIBITION PROBLEMS

I say things without thinking(Required)
I do things without thinking(Required)
I do not follow directions(Required)
I dominate conversations (for example: I talk more than other people in a conversation)(Required)
I interrupt when others are speaking(Required)

PHYSICAL & SENSORIMOTOR PROBLEMS

My body hurts a lot of the time(Required)
I don't get enough sleep(Required)
I feel tired(Required)
I am bothered by light(Required)
I have a hard time focusing my eyes(Required)
I have a hard time telling how near or far away objects are from me(Required)

LANGUAGE PROBLEMS

I have a hard time understanding what people tell me(Required)
I have a hard time understanding what I've read(Required)
I have a hard time finding the right word when speaking(Required)
I have a hard time getting people to understand what I am trying to say(Required)
I have a hard time finding the right words when writing(Required)

ORGANIZATION PROBLEMS

I have a hard time deciding which of my daily tasks I should do first(Required)
I have a hard time keeping to a schedule(Required)
I have a hard time keeping to a schedule(Required)
I have a hard time starting tasks(Required)
I have a hard time switching from one task to another(Required)
I have a hard time completing tasks(Required)
I have a hard time completing tasks correctly(Required)
I have a hard time completing tasks on time (paying bills, work activities)(Required)

MENTAL FLEXIBILITY PROBLEMS

I have a hard time figuring out how to handle new problems(Required)
I have a hard time changing my mind when things change(Required)
I have a hard time learning new ways of doing things(Required)
I don’t understand why people do things differently than me(Required)

EMOTIONAL PROBLEMS

I feel anxious(Required)
I feel irritated(Required)
I cry easily(Required)
I feel depressed(Required)
I overreact to things(Required)
I feel traumatized(Required)
ex: tell us about any words or phrases within the form that were challenging for the client
Language preference for tip sheets?