ACUTE TRAUMATIC BRAIN INJURY SCREENING TOOL

Date: ___/____/_____
Patient: _________________
Evaluator:_____________
1. ORIENTATION:
Person Situation
Place Object
Time Oriented X ___=_

2. MEMORY: read the five words

below. As the patient to repeat them
back to you. Repeat one time if
necessary. You will ask them to recall
them again later in the test.
Book House
Piano Yellow
Rose #Correct/5: ____

4. PROBLEM SOLVING: Ask the pt to draw 10 pepperonis on the pizza.

Next, ask the pt to answer the following: A
pizza chef has 30 pepperonis and wants the
same amount on each slice. How many
pepperonis can he put on each slice? Show
your work if you would like.

#Correct/2:____
6. VISION: Scanning, acuity.
Using a hospital menu, ask the pt three
questions about the menu. Examples:
What flavors of ice cream are available?
What can you order for lunch?
What time is dinner delivered?
Observations: __________________
____________________________
____________________________
8. VISUAL PERCEPTION:
Ask the pt to identify which shape is
different in each row. #Correct/3:____

7. LONG TERM MEMORY: Ask

the pt to recall the five words
from item 2.
Book House
Piano Yellow
Rose #Correct/5: ____

3. MEMORY and ATTENTION Read the

following paragraph and ask the pt to
answer the questions.
Before eating breakfast, Johnnie had to
shovel the sidewalk, as over a foot of
snow had fallen over night. Once
finished, Johnnie was so cold that he
took a shower. He then made scrambled
eggs and hot chocolate.
a. What is the persons name?
b. What time of day is it?
c. What did the person in the story do?
d. What did the person eat?
# Correct/4: ____
5. ACTIVE ROM AND MANUAL
MUSCLE SCREENING:
Circle and describe any concerns.
Shoulder: (flex, extend, elevate, rotate,
ab/adduct)
____________________________
Elbow: (flex, extend, pronate, supinate)
____________________________
Wrist: (flex, extend, deviate)
____________________________
Fingers/thumb: (flex, extend, ab/adduct)
____________________________

9. FUNCTIONAL ASSESSMENT: Ask the person to go to the sink to brush their

teeth. If pt is non-ambulatory, gather the supplies and ask them to do it either
in bed or sitting edge of bed. Use a hierarchy of cueing when assisting patient
in task. Make notes in the following areas during observation:
Balance:_________________________________________________
Following directions: ________________________________________
Attention to task:___________________________________________
Impulsivity:______________________________________________
Apraxia:_________________________________________________
Sequencing: _____________________________________________
Motor coordination: ________________________________________
Other notes: ______________________________________________
_______________________________________________________