Brain Injury Information Center

Brain Injuries Contact Form

Name

Email Address

Phone Number

Business Phone

Cellular or Pager

Address

City

State

Zip

Cause of the injury:
Car accident
Work-related accident
Sports or recreational accident
Possible medical malpractice
Assault
Other

Symptom(s) that have been experienced:
None
Headaches
Dizziness
Vertigo
Loss of sleep
Memory loss
Difficulty with numbers
Sensitivity to light
Depression
Personality change

Diagnostic tools that medical professionals have used to determine the extent of the injury:
None
MRI
CT Scan
PET Scan
EEG
Other(s):

Has occupational or physical therapy been utilized?
Yes
No
Not Sure

Any other information or concerns?

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