Traumatic Brain Injury or Head Injury / Trauma Questionnaire:

 Let’s take a look at the risk factors which may indicate a closed head injury or the results of trauma to head and neck areas.. Check yourself for possible hidden head injuries / neck injuries.  Answer each box that applies to your experiences. Rate yourself: If you have experienced the description of the questions even once,  answer "Yes". If you never have  experienced this description of the the question, answer "No". 

Yes No    1. Were you a forceps delivered baby?

Yes No    2. Did you have a difficult birth?

Yes No    3. Did you have to take any drugs when you were newly born?

Yes No    4. Did you stay in the hospital longer than three days at birth?

Yes No    5. Were you a premature birth?

0 3 4 5 6        6. How many months premature ( place a 3, 4, 5, 6 in the box)

Yes No    7. Were you a natural birth without pain medication for your mom?

Yes No    8. Were you a caesarian birth?

Yes No    9. Did you have any surgeries in the first 9 months after birth?

Yes No    10.Was your head shape distorted as a baby

Yes No    11. Did you have to wear corrected shoes for feet turned inward  outward?

Yes No    12. Have you ever worn braces? Mouth splint?

Yes No    13. Do you have crooked teeth?

Yes No    14.Have you ever had teeth extracted?

Yes No    15. Have you ever had teeth extracted to make room in your mouth for your braces?

Yes No    16. Have you ever worn a mouth expanding appliance to build your mouth larger?

Yes No    17. Do you have an silver mercury amalgam fillings in your mouth?

Yes No    18. Do you have any crowns in your mouth?

Yes No    19. Do you know what metals are in the crowns?

Yes No    20. Do you have any root canal work in your mouth?

Yes No    21.  Have you ever had cavitation surgery?

Yes No    22.  Have you ever had Implants?

Yes No    23.  Do you wear non-natural teeth or false teeth?

Yes No    24. Have you ever been labeled as having TMJ problems?

Yes No    25.  Is your chin recessed?

Yes No    26. Does your head jut forward?

Yes No    27. Do you have difficulty keeping your head even with your shoulders?

Yes No    28. Do you have asymmetry in your facial features?

Yes No    29. When you look at your eyes, are they levels?

Yes No    30. When you look at your eyebrows, are they about the same height?

Yes No    31. When you look at your ears, are they level?

Yes No    32. Have you ever fallen down?

Yes No    33. Have you hit your head or shoulder in a fall?

Yes No    34. Have you fallen on your tail bone?

Yes No    35. Have you ever banged your head: on a cabinet, a door,  getting out of the car?

Yes No    36. Have you ever had a car accident?  This includes fender benders

Yes No    37. Have you ever ridden a roller coaster, or bumper cars?

Yes No    38. Have you ever banged your head playing sports, (soccer, basketball, football)

Yes No    39. Have you ever played football?

Yes No    40. Have you ever high dived (swimming) and hit your head on the bottom?

Yes No    41. Have you ever done a bad belly flop off the side of the pool? 

Yes No    42. Have you ever been involved in gymnastics and fallen to the floor?

Yes No    43. Have you ever been pregnant?

Yes No    44. Have you ever been labeled, ADD, ADHD, dyslexic, learning disability?

Yes No    45. Have you ever been on Ritalin to control hyperactivity? ADD, ADHD?

Yes No    46. Have you ever been labeled as Chronic Fatigue Syndrome or Fibromyalgia?

Yes No    47. Do you experience drops of energy on and off throughout the day?

Yes No    48. Do you experience mood swings, emotional outbursts? and hopelessness?

Yes No    49. Are you overweight and can’t seem to lose weight?

Yes No    50. Do you gain weight in abdomen and thighs, pear shaped body?

Yes No    51. Have you ever experienced an eating disorder?

Yes No    52. Do you try to gain weight and can’t?

Yes No    53. Do you feel the need for coffee or sugar snacks to pick you up?

Yes No    54. Do you have headaches? 

Yes No    55. Do you have unexplained body or joint pain?

Yes No    56. Do you have irregular or painful menstrual cycles ?

Yes No    57. Do you have difficulty coping with stressful situations?

Yes No    58. Do you “catch” colds/flu/bronchitis frequently?

Yes No    59. Do you have trouble remembering things? short term or long? 

Yes No    60. Do you have numbness or tingling in any part of your body?

Yes No    61. Do your arms, hands, legs, or feet shake?

Yes No    62. Have you ever experienced Bells Palsy Symptoms?

Yes No    63. Have you ever experienced a stroke?

Yes No    64. Do you have digestive problems?  Gastric Reflux? Ulcers? Leaky Gut? 

Yes No    65. Do you have hemorrhoids, Diverticulitis, colitis, or irritable bowel syndrome?

Yes No    66. Do you have chest pain or shortness of breath?

Yes No    67. Do you experience “chronic” gallbladder pain?

Yes No    68. Have you had gallbladder surgery?

If you answer "YES" answer to more than twenty  questions, you have tendencies toward  head injuries and brain trauma, which links to other systems in the body creating a network of deeper layers and causes. There are multiple causes, and multiple energies thrust into your body in a blow to the head. These disruptions of brain function can be caused by sound at impact, hidden pain levels,  electrostatics, electromagnetics, pressure changes, deceleration, blood pressure changes, adrenal changes,  infrared, slamming your brains internal environment into the skull, etc.   Most people ignore this because they don't have broken bones. Yet the soft tissue injury is often the most damaging injury.  Early primitive reflexes are triggered causing the brain to act like a little baby and an adult at the same time. The sad thing is these early traumas are still active causing reflex aches, pains and restriction we don't remember or know where to find to stop their actions.  No wonder there's confusion after a car accident. All this says is that you learned some very traumatic postures and neurological habits in a couple of traumatic seconds that may take years to unravel. To clarify this see car accident trauma, frozen shoulder, functional endocrinology,  head injury, Hiatal Hernia, spine trauma, or you may which to evaluate yourself with other self tests.

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We have developed some very advanced methods that give you multiple choices or alternatives to your present head trauma or injury.   After taking the test above, send the results to us with the information below. We'll get back to you by E-mail within a week. We will give you an overview and a new perspective of what can be done. Or you can call our office for an appointment and consultation. 706-379-1225

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