Recommended time for assessment:
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1 Recommended time for assessment: Basic Intermediate Advanced FIMTM: (see attachment 1) - Entry to rehab - Discharge rehab - 1 month post injury - 3 months post injury NSI: (see attachment 2) - Entry to rehab - Discharge rehab - 1 month post injury - 3 months post injury PTSD checklist: (see attachment 3) - Admission to study hospital - Entry to rehab - 1 month outcome - 3 months outcome
2 Basic POST DISCHARGE / OUTPATIENT CARE Visit date: VISIT DATE STATUS Status: Dead Alive Please complete section on death information Please continue SOCIOECONOMIC STATUS Patient s residence: At home Hospital Rehab center Nursing home Returned to work/school: Returned to previous level Same work/school, reduced level Different work/school Only in sheltered environment N/A Returned to other activities: Full return to previous level Reduced level POST DISCHARGE / OUTPATIENT TREATMENT Medication: Yes: Psycho-stimulants Anticonvulsants Pain killers Antidepressants Surgery: Intracranial Yes Extracranial Yes Rehabilitation: Out-patient rehabilitation Duration of out-patient rehab: days n-specialised facility (in-patient) Specialised rehab center (in-patient) Duration of in-patient rehab: days
3 Intermediate POST DISCHARGE / OUTPATIENT CARE VISIT DATE Visit date: STATUS Status: Dead Alive Please complete section on death information Please continue SOCIOECONOMIC STATUS Patient s residence: At home Hospital Rehab center Nursing home Marital status: Never been married Married/Living together/common law Separated Divorced Widowed Persons living with*: Alone Spouse (including common law partner) Parents Siblings Child/children Significant other partner (incl. correctional facility inmates) * Multiple entries permitted Number of people living with: Please enter number Returned to work/school: Returned to previous level Same work/school, reduced level Different work/school Only in sheltered environment N/A Returned to other activities: Full return to previous level Reduced level
4 POST DISCHARGE / OUTPATIENT TREATMENT Medication: Yes: Psycho-stimulants Anticonvulsants Narcotics pain medication Steroids Antibiotics Antidepressants Antipsychotic agents s Surgery: Intracranial Yes If yes: Hydrocephalus Chronic Subdural Hematoma Cranioplasty, specify: Date surgery: Extracranial Yes If yes: please specify: Date surgery:
5 Rehabilitation: Out-patient rehabilitation General rehab unit (in-patient) TBI rehabilitation unit (in-patient) General long term acute care unit (in-patient) Geriatric rehab unit (in-patient) If treated as in-patient: Date admission to rehab: Date discharge rehab: Short term rehabilitation interruptions: First interruption start date: Second interruption start date: First interruption end date: Second interruption end date: If treated as outpatient: Date start outpatient Rehab therapy: Active rehab therapy ongoing: If no, date end outpatient rehab therapy: Yes Type of outpatient therapy*: * Please, mark all that apply. Physical therapy Occupational therapy Speech therapy Therapeutic recreation Cognitive remediation Vocational services Psychological services Nursing services Comprehensive day treatment Peer mentoring Social work/case management Independent living training Home health :
6 Advanced POST DISCHARGE / OUTPATIENT CARE Visit date: VISIT DATE STATUS Status: Dead Alive Please complete section on death information Please continue SOCIOECONOMIC STATUS Patient s residence: At home Hospital Rehab center Nursing home Marital status: Never been married Married/Living together/common law Separated Divorced Widowed Persons living with*: Alone Spouse (including common law partner) Parents Siblings Child/children Significant other partner (incl. correctional facility inmates) * Multiple entries permitted Number of people living with: Please enter number Returned to work/school: Returned to previous level Same work/school, reduced level Different work/school Only in sheltered environment N/A Returned to other activities: Full return to previous level Reduced level
7 POST DISCHARGE / OUTPATIENT TREATMENT Medication: Yes: Psycho-stimulants Anticonvulsants Narcotics pain medication Steroids Antibiotics Antidepressants Antipsychotic agents s Surgery: Intracranial Yes If yes: Hydrocephalus Chronic Subdural Hematoma Cranioplasty, specify: Date surgery: Extracranial Yes If yes: please specify: Date surgery:
8 Rehabilitation: Out-patient rehabilitation General rehab unit (in-patient) TBI rehabilitation unit (in-patient) General long term acute care unit (in-patient) Geriatric rehab unit (in-patient) If treated as in-patient: Date admission to rehab: Short term rehabilitation interruptions: First interruption start date: Second interruption start date: Date discharge rehab: First interruption end date: Second interruption end date: If treated as outpatient: Date start outpatient Rehab therapy: Active rehab therapy ongoing: If no, date end outpatient rehab therapy: Yes Type of outpatient therapy*: Physical therapy Occupational therapy Speech therapy Therapeutic recreation Frequency**, only if marked: ** 1 = ne 2 = Only follow-up, no active treatment 3 = < once per week 4 = weekly 5 = 2-3 times/week 6 = Daily 7 = Cognitive remediation Vocational services Psychological services Nursing services Comprehensive day treatment Peer mentoring Social work/case management Independent living training Home health : * Please mark all that apply.
9 Attachment 1 FIMTM FIMTM Scale: Functional Independence Measure (FIM) Scale 1. Feeding: 0-7;9 2. Grooming: 0-7;9 3. Bathing: 0-7;9 4. Dressing Upper Body: 0-7;9 5. Dressing Lower Body: 0-7;9 6. Toileting: 0-7;9 8. Bladder Management: 1-7;9 8a. Bladder Management LEVEL OF ASSISTANCE: 1-7;9 8b. Bladder Management FREQUENCY OF ACCIDENTS: 1-7;9 9. Bowel Management: 1-7;9 9a. Bowel Management LEVEL OF ASSISTANCE: 1-7;9 9b. Bowel Management- FREQUENCY OF ACCIDENTS: 1-7;9 10. Bed, Chair, Wheelchair Transfers: 0-7;9 11. Toilet Transfers: 0-7;9 12. Tub or Shower Transfers: 0-7;9 14a. Walking: 0-7;9 14b. Wheelchair: 0-7;8;9 15. Stairs: 0-7;9 17a. Comprehension MODE: a;v;b;9 17b. Comprehension: 1-7;9 18a. Expression MODE: v;n;b;9 18b. Expression: 1-7;9 22. Social Interaction: 1-7;9 26. Problem Solving: 1-7;9 27: Memory: 1-7;9 FIM Codes: Activity does not occur-admit items 1 through 6 and 10 through 15 only Total Assistance (pt <25 % of task) Maximum Assistance (pt % of task) Moderate Assistance (pt % of task) Minimal Assistance (pt >75 % of task) Supervision (pt does 100 %) Modified Independence (extra time, device) Complete Independence (timely, safely) N/A pt walking/not using wheelchair item 14b. only or assessed at >72 hours Frequency of Accidents Codes: Five or more accidents in past 7 days Four accidents in past 7 days Three accidents in past 7 days Two accidents in past 7 days One accident in past 7 days accidents, uses device accidents or assessed at >72 hours
10 Attachment 2 Neurobehavioral Symptom Inventory: Neurobehavioral Inventory List Rate the following syptoms with regard to how much they have disturbed you IN THE PAST TWO WEEKS. (ONLY TO BE COMPLETED BY PERSON WITH TBI) 1. Feeling dizzy: 0-4;9 2. Loss of balance 0-4;9 3. Poor coordination, clumsy: 0-4;9 4. Headaches: 0-4;9 5. Nausea: 0-4;9 6. Vision problems, blurring, trouble seeing: 0-4;9 7. Sensitivity to light: 1-4;9 8. Hearing difficulty: 1-4;9 9. Sensitivity to noise: 0-4;9 10. Numbness or tingling on parts of my body: 0-4;9 11. Change in taste and/or smell: 0-4;9 12. Loss of appetite or increase of appetite: 0-4;9 13. Poor concentration, can t pay attention, easily distracted: 0-4;9 14. Forgetfulness, can t remember things: 0-4;9 15. Difficulty making decisions: 0-4;9 16. Slowed thinking, difficulty getting organized, can t finish things: 0-4;9 17. Fatigue, loss of energy, getting tired easily: 0-4;9 18. Difficulty falling or staying asleep: 0-4;9 19. Feeling anxious or tense: 0-4;9 20. Feeling depressed or sad: 0-4;9 21. Irritability, easily annoyed: 0-4;9 22. Poor frustration tolerance, feeling easily overwhelmed by things: 0-4;9 Codes: 0 = ne rarely if ever present; not a problem at all 1 = Mild Occasionally present, but it does not disrupt activities, I can usually continue what I m doing; doesn t really concern me. 2 = Moderate Often present, occasionally disrupts my activities; I can usually continue what I m doing with some effort; I feel somewhat concerned. 3 = Severe Frequently present and disrupts activities; I can only do things that are fairly simple or take little effort; I feel like I need help. 4 = Very severe Almost always present and I have been unable to perform at work, school or home due to this problem; I probably cannot function without help. 9 = or assessed at >72 hours
11 Attachment 3 PCL-C PTS CHECKLIST: Post Traumatic Stress Disorder Checklist Civilian Version (PCL-C): Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please indicate how much you have been bothered by the following IN THE PAST MONTH. (ONLY TO BE COMPLETED BY PERSON WITH TBI) At Admission to PRC 1. Repeated, disturbing memories, thoughts or images of a stressful experience from the past 2. Repeated, disturbing dreams of a stressful experience from the past 3. Suddenly acting or feeling as if a stressful experience from the past were happening again (as if you were reliving it) 4. Feeling very upset when something reminded you of a stressful experience from the past 5. Having physical reactions (i.e. heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience from the past 6. Avoiding thinking about or talking about a stressful experience from the past or avoiding having feeling related to it 7. Avoiding activities or situations because they reminded you of a stressful experience from the past 8. Trouble remembering important parts of a stressful experience from the past 9. Loss of interest in activities that you used to enjoy 10. Feeling distant or cut off from other people 11. Feeling emotionally numb or being unable to have loving feelings to those close to you 12. Feeling as if your future will somehow be cut short 13. Trouble falling or staying asleep 14. Feeling irritable or having angry outbursts 15. Having difficulty concentrating 16. Being super alert or watchful or on guard 17. Feeling jumpy or easily startled 1 = not at all 2 = a little bit 3 = moderately 4 = quite a bit 5 = extremely 9 = unknown/not sure
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