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Neurological Assessment: Symptoms and Signs Present

[Study Name/ID pre-filled] Site Name:


Subject ID:
1. Does participant/subject display the following TBI symptom or sign?
a. Headache Yes No Unknown
b. Nausea Yes No Unknown
c. Vomiting Yes No Unknown
d. Balance problems Yes No Unknown
e. Fatigue Yes No Unknown
f. Sensitive to light Yes No Unknown
g. Sensitive to noise Yes No Unknown
h. Numbness/tingling Yes No Unknown
i. Drowsiness Yes No Unknown
j. Sleeping less than usual Yes No Unknown
k. Sleeping more than usual Yes No Unknown
l. Difficulty falling asleep Yes No Unknown
m. Feeling mentally foggy Yes No Unknown
n. Feeling slowed down Yes No Unknown
o. Difficulty concentrating Yes No Unknown
p. Difficulty remembering Yes No Unknown
q. Irritability Yes No Unknown
r. Sadness Yes No Unknown
s. More emotional Yes No Unknown
t. Nervousness Yes No Unknown
u. Other, specify Yes No Unknown
Additional Supplemental Elements:
These elements may be included if relevant to the study.
2. TBI symptom or sign category:
Physical
Sleep
Cognitive
Emotional
Other
3. TBI symptom or sign rating code (adult only): 1 (Normal) 2 3 4 5 6 (Very Different)
4. TBI symptom worsens with cognitive activity (adult only): Yes No Unknown
5. TBI symptom worsens with physical activity (adult only): Yes No Unknown
6. Orientation to person result: Abnormal Normal
7. Orientation to place result: Abnormal Normal

TBI CDEs Version 4.0 Page 1 of 2


Neurological Assessment: Symptoms and Signs Present
[Study Name/ID pre-filled] Site Name:
Subject ID:
8. Orientation to time result: Abnormal Normal

TBI CDEs Version 4.0 Page 2 of 2