Head Injury Form

Today's Date:

Patient’s Name:

Date of Birth:

Check this box if you don’t have any brain injury

If there was an impact to your head - please use this diagram to show ‘where’ on your head. Use the marks shown below to provide details.
(please be as accurate as possible)

Please click and use these above markings to show what happened to your head on the day of injury.

Write in additional comments as

If you are not able to fill the diagram form online, please download the diagram, print it and add the markings over it.

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