Name *(Required) E-mail *(Required) Phone Number *(Required) Queries SYMPTOM CHECKLIST The following is a list of difficulties and feelings which people sometimes have after an injury. Please indicate which ones you have experienced since your injury by ticking the column. If you have not experienced the symptom since your recent injury, leave it blank. Thank you! SYMPTOM Yes/No Often have headaches Difficulty remembering Have felt depressed or find difficulty becoming interested in anything Often lose temper or get upset more easily than before Often feel anxious or tense Suffer from dizziness Have difficulty concentrating, reading or following a conversation Have difficulty with eyes Often troubled by too much noise Have difficulty speaking Often irritable or angry Become tired very easily Have difficulty sleeping Enter Code Verification Code
