Persistent Intellectual Impairments |
Check | Score | Note |
| 1.1 Memory problems | Yes | 3 | |
| 1.2 Difficulty concentrating | Yes | 3 | |
| 1.3 Attention Difficulties | Yes | 3 | |
| 1.4 Easily Distracted | Yes | 3 | |
| 1.5 Misplacing or difficulty tracking things | Yes | 3 | |
| 1.6 Difficulty making decisions | Yes | 3 | |
| 1.7 Difficulty solving problems | Yes | ||
| 1.8 Difficulty understanding spoken instructions | 0 | ||
| 1.9 Difficulty understanding written instructions | Yes | 3 | |
| 1.10 Difficulty finding words | Yes | 3 | |
| 1.11 Difficulty communicating thoughts / feelings | Yes | 3 | |
| 1.12 Unintentionally repeating the same remarks | 0 | ||
| 1.13 Unintentionally repeating same activities | Yes | 2 | Forgot I had done them the first time. |
| 1.14 Stuttering or stammering | 0 | Not observed | |
| 1.15 Difficulties doing simple math | 0 | Problems with reimbursement organization not the math | |
| 1.16 Impaired abstraction or literalness | literalness | Tend toward doing small detail things and not seeing larger context | |
| 1.17 Mental rigidity | Yes | Follow fixed routine and travel patterns | |
| 1.18 Deficits in processing information | Yes | 3 | Miss errors. Need multiple reviews. Misinterpret, misunderstand. Not sure of state |
| 1.19 Deficits in sequencing information | ?? | Not sure what this means | |
| 1.20 Difficulty executing or doing things | Yes | 3 | Will start and then leave and go on to something else. Lots of incomplete projects. |
| 1.21 Difficulty starting or initiating things | Yes | 3 | Real need to push to move outside “comfort zone.” Tend to revert to routine. |
| 1.22 Difficulty handling work requirements | ?? | Have to push myself to complete Dr assignments, letters etc | |
| 1.23 Difficulty handling school requirements | ?? | N/A | |
| 1.24 Having to check and re-check what you do | Yes | 3 | Yes, especially safety / security items stove, car keys, house keys, documents |
| 1.25 Disoriented by slight changes in daily routine | Yes | 3 | Yes. Become uncomfortable |
| 1.26 Unsure about things that you know well | Yes | 3 | Sense that I am not making adequate perceptions. Spend time mulling events over. |
| 1.27 Difficulty learning new things | Yes | 3 | HTML 5, css3, js |
| 1.28 Doing things slowly to insure correctness | Yes | 3 | Yes. Documents undergo endless revision. Paper management frustration. |
| 1.29 Decreased capacity for reality testing | ? | Not sure what this means | |
| 1.30 Impaired ability to appreciate details | Not sure what this means | ||
| 1.31 Impaired ability to benefit from experience | Not sure what this means | ||
| 1.32 Inappropriate responses to people & things | Yes | 3 | Pushy and impolite in crowded store |
| 1.33 Difficulty taking care of your self | Yes | 3 | Wounds, open sores |
| 1.34 Difficulty taking care of children | N/A | ||
| 1.35 Sect 1 TOTALS | 57 | ||
| Psychological Consequences | Check | Score | Note |
| 2.1 Impaired sense of self | Yes | 2 | |
| 2.1 Fear of loss of control | Yes | 2 | Dementia, things no longer under my control or as expected |
| 2.3 Easily agitated or irritated | Yes | 3 | SAAQ |
| 2.4 Easily startled | 0 | Not noted. Have startle response in absence of stimulus | |
| 2.5 Feelings of paranoia | Yes | 2 | Yes. Afraid to mention this as thought it would be weird |
| 2.6 Spells of terror or panic | Yes | 3 | Have sense of this in exiting crowded or noisy spaces. But not panic as I know it |
| 2.7 Feelings of depression | Yes | 3 | Feeling of “down” rather than the heavy quality of what I call depression |
| 2.8 Feelings of shame or guilt | Yes | 3 | Feel all this is my fault. That I should have done something sooner. I am weakling. |
| 2.9 Persistent anxiety | No | 0 | No anxiety at all. This seems odd. |
| 2.10 Anxiousness or feelings of fear and dread | No | 0 | Have sense of wanting to be “safe” |
| 2.11 Feelings of discouragement | Yes | 2 | Not sure if improving or getting worse. Make same mistake over and over. |
| 2.12 Withdrawal or social isolation | Yes | 2 | Not by choice. Consequence of crazy work schedule and job loss |
| 2.13 Feeling others not appreciating your difficulties | Yes | 3 | Fear of others |
| 2.14 Feeling everything is an effort | Yes | 3 | Constant vigilance |
| 2.15 Feeling inept or worthless | Inept | 2 | Mostly inept but also both. Job rejection. Social rejection. |
| 2.16 Laughing or crying without apparent cause | Yes | 0 | Had this previously. Not seen recently. Did cry when starting walks. |
| 2.17 Worrisome thoughts won’t leave your mind | 0 | ||
| 2.18 Making up explanations for things | 0 | ||
| 2.19 Insensitive to others and social context | Yes | 3 | Crowded places |
| 2.20 Diminished insight | Yes | 2 | Have to work at understanding. In some cases very vibrant insight, recollection etc. |
| 2.21 Sect 2 TOTAL | 33 | ||
| Persistent Mood Disorders | Check | Score | Note |
| 3.1 Mood swings | Yes | 3 | Walking helps even this out. Feel down and go for walk. |
| 3.2 Having urges to beat, injure or harm someone | No | 0 | |
| 3.3 Shouting or throwing things | No | 0 | I may have been shouting at SAAQ. Tempted to throw in frustration. |
| 3.4 Temper outbursts that you could not control | Yes | 3 | SAAQ. Also work conflict, conflict with Val, outbursts. |
| 3.5 Sect 3 TOTAL | 6 | ||
| Persistent Physiological Impairments | Check | Score | Note |
| 4.1 Heart pounding or racing | No | 0 | Have noted this but not recently |
| 4.2 Rapid pulse | No | 0 | Very slow and stable pulse. |
| 4.3 Headaches or head pains | Yes | 2 | Have headaches and “discomfort” which is less than what I would call a headache |
| 4.4 Increased blood pressure | ? | 0 | |
| 4.5 Increased sensitivity to touch | ?? | 0 | Do not think so |
| 4.6 Ringing in ears | Yes | 2 | Started again after starting walks. Present all the time. |
| 4.7 Easily fatigued | Yes | 3 | After Dr sessions, after walks, after paperwork |
| 4.8 Numbness or tingling in parts of your body | No | 0 | Noticed in months right after the accident. Feet appeared numb |
| 4.9 Weakness or loss of strength | Yes | 0 | Hitting the wall with no caffeine. Dropped things after accident. |
| 4.10 Feeling tense or keyed up | No | 0 | |
| 4.11 Restlessness, unable to sit still | No | 0 | Opposite. Would sit still all day. Did pace a lot during job search. |
| 4.12 Lessened ability to perform physically | Yes | 3 | Blame this on caffeine |
| 4.13 Decreased tolerance for alcohol and drugs | N/A | 0 | Do not use |
| 4.14 Appetite disturbances | 0 | very routine meal, menu | |
| 4.15 Trouble falling asleep | Yes | 3 | Working on this at 2 am as unable to sleep |
| 4.16 Awakening during the night | Yes | 3 | Get up at 3 or 4 have tea. Used to start job hunt during this time |
| 4.17 Sleep that is restless or disturbed | Yes | 3 | Wake up thinking I have missed appointment, very vibrant dream, think I am in dream |
| 4.18 Sect 4 TOTAL | 19 | ||
| Persistent Personality Alterations | Check | Score | Note |
| 5.1 Passivity, or submissiveness | No | 0 | Don’t think so |
| 5.2 Aggressiveness | No | 0 | Don’t think so |
| 5.3 Apathy, lack of interest or emotion | Yes | 4 | Changed in Past year. Less apathetic |
| 5.4 Overly sensitive | ?? | 0 | Don’t think so |
| 5.5 Discouragement or demoralization | Yes | 3 | Changed in Past year. More discouraged |
| 5.6 Increased emotional distress | No | 0 | Changed in Past year. More emotional distress |
| 5.7 Chronic frustration | Yes | 3 | Very easily frustrated when faced with relatively simple tasks |
| 5.8 Grandiosity or boastfulness | No | 0 | Don’t think so |
| 5.9 Excessively talkative | Yes | 2 | Dr D mentioned this. Excessive detail |
| 5.10 Compulsive writing | Yes | 2 | Yes. Taking notes on all weirdness. Notes for projects etc |
| 5.11 Egocentricity | No | 0 | Don’t think so |
| 5.12 Childishness | No | 0 | Don’t think so |
| 5.13 Silliness | No | 0 | Don’t think so |
| 5.14 Overly responsible | No | 0 | |
| 5.15 Irresponsibility | No | 0 | |
| 5.16 Impulsively | No | 0 | |
| 5.17 Self-indulgent | No | 0 | Maybe. Video phone affair. |
| 5.18 Indiscreet comments and acts | No | 0 | |
| 5.19 Obscene comments or acts | No | 0 | |
| 5.20 Increased sexual activity | No | 0 | |
| 5.21 Decreased sexual activity | Yes | 4 | |
| 5.22 Increased shame or guilt | No | 0 | |
| 5.23 Religiosity | No | 0 | |
| 5.24 Sect 5 TOTAL | 14 | ||
| Persistent Neurological Problems | Check | Score | Note |
| 6.1 Sense of observing your self from afar | ?? | 0 | I am trying to be more self-observant// Also disassociation issue |
| 6.2 Altered consciousness | ?? | 0 | Not sure what this means |
| 6.3 Slowed reaction time | Yes | 3 | |
| 6.4 Smelling odors that others do not smell | Yes | 2 | No others to check but I suspect the smells are phantoms – kitchen cupboard, hall |
| 6.5 Hearing music that others do not hear | Yes | 2 | Complained to condo association |
| 6.6 Making up explanations for things | No | 0 | |
| 6.7 Sensitivity to temperature shifts | Yes | 2 | Have noted this but did not see it as due to TBI |
| 6.8 Seeing dark spots before your eyes | No | 0 | |
| 6.9 Blurred vision, especially when fatigued | Yes | 3 | Happens regularly but at short distances |
| 6.10 Double vision especially when fatigued | No | 0 | Not recent but yes in months after accident |
| 6.11 Diminished night vision | Yes | 2 | Have had a sense of this but did not see it as due to TBI |
| 6.12 Difficulty relaxing | |||
| 6.13 Twitching | Yes | 2 | Did have this on months after accident. Much reduced now. Nipped tongue. Startle. |
| 6.14 Sensitivity to sound or noise | Yes | 3 | Problems in crowded, noisy spaces |
| 6.15 Sensitivity to light | No | 0 | |
| 6.16 Sect 6 TOTAL | 20 |
Note
This table seeks to accurately reflect the data contained in the original, paper based, TBI inventory document completed in September 2012. A copy of this TBI Inventory was forwarded to SAAQ in August of 2013 as an element in the initial appeal submission. If there are blanks in this web document that is because those items were left blank, or were not scored, in the submitted version. The section totals were tabulated by hand and contain tabulation errors. This version preserves those errors, and seeks to provide an exact duplicate of the submitted paper version.