Person Completing Form: Relationship to patient:

Date of Rehab Admission: Date Form Completed: € Admit € D/C

Introduction: As a family member or friend of someone with a traumatic brain injury (TBI), it is likely you have many questions about their present condition and their future recovery. Providing you with information about TBI is an important part of our Rehabilitation Program. The following survey will help us identify the topics that are currently most important to you.

Directions: After each of the following 20 questions, please check the box indicating if you need more information in this area. You can use the space provided below each item if you have specific questions or concerns that you would like addressed.

Team responsibilities	Please indicate if you need for more information in the areas below.	YES, I need more information on this topic.		NO I already understand this material.		? I don’t know. (maybe later)
MD	1. Basic information about traumatic brain injury (TBI): What is a TBI? What are the details about my family member’s injury? What parts of the brain were injured?					
Any specific questions?
MD	2. TBI Recovery Course: How long does recovery from TBI take? Are there usually any permanent impairments or changes?					
Any specific questions?
Nsg	3. The Rehabilitation Team: Who are the team members on Rehab and what are their roles in caring for my family member?					
Any specific questions?
Nsg	4. Care Communication: How will communication be maintained with me about my family member’s care and status? Who do I talk to about questions or concerns I may have?						
Any specific questions?
Nsg	5. Family Involvement: How much will we be included in the care of our family member? Can we go to therapies to observe? When is the best time for visitors to come to Rehab?						
Any specific questions?

Team responsibilities	Please indicate if you need for more information in the areas below.	YES I need more information on this topic	NO I already understand this material.	? I don’t know. (maybe later)
MD	6. Current Medical Issues: What medical issues is my family member currently facing?			
Any specific questions?
Nsg	7. Medications: What medications is my family member taking? What are they for? How long will they need to be taking them?			
Any specific questions?
MD	8. Future Medical Concerns: Are there any future medical problems that my family member faces because of TBI (seizures, headaches, chronic pain, infections, infertility)?			
Any specific questions?
PT OT	9. Physical Consequences: What are the physical consequences of TBI that my family member faces (weakness, balance, coordination, vision changes)? What can I do to help my family member in this area?			
Any specific questions?
SLP	10. Cognitive Impairments: What are the mental or thinking problems that occur with TBI (memory, attention, orientation)? What can I do to help my family member in this area?			
Any specific questions?
SLP	11. Communication Challenges: What are the communication difficulties associated with TBI (speech, comprehension, reading)? What can I do to help my family member in this area?			
Any specific questions?
Med y	12. Emotional Issues: What are the emotional changes that can be expected following a TBI (depression, irritability, anxiety, self-esteem issues)? What can I do to help my family member in this area?			
Any specific questions?

Team responsibilities	Please indicate if you need for more information in the areas below.		YES I need more information on this topic		NO I already understand this material.		? I don’t know. (maybe later)
Med y	13. Behavioral Changes: What behavioral changes can occur following a TBI (impulsivity, agitation, withdrawal, sexuality issues)? What can I do to help my family member in this area?						
Any specific questions?
Med y SLP	14. Fatigue after TBI: Why is my family member so tired all the time? What causes increased fatigue after TBI? What can be done to prevent fatigue or to increase their energy?						
Any specific questions?
SW	15. Support for Family: Who can I talk to about feelings I am having now? Are there support groups or other services to help us cope after we leave Inpatient Rehab?						
Any specific questions?
Team	16. Discharge Preparation: How much help will my family member need after leaving the hospital? What therapies or services will they require, and how will they be provided? Will there need to be someone with them all the time?						
Any specific questions?
SLP OT	17. Safety After Discharge: Are there things that my family member shouldn’t do after having a TBI because of safety issues? What should we do to make certain they are safe after coming home from the Inpatient Rehab Unit?						
Any specific questions?
Med y	18. Alcohol and Drug Use: What should we know about the effects of alcohol or drugs on a recovering brain? What services are available to help my family member address these issues?						
Any specific questions?
OT SLP RT	19. Community Re-entry: Will my family member be able to return to his or her usual activities once home, such as driving, working, school or recreational interest? Who will decide if, and when, they can return to these activities?					
Any specific questions?
Team responsibilities	Please indicate if you need for more information in the areas below.	YES I need more information on this topic		NO I already understand this material.		? I don’t know. (maybe later)
SW	20. Community Resources: What agencies or services are available in the community to help us once we leave inpatient Rehab? Who will help us learn about, and access resources like Medicaid Waiver, Voc Rehab or Brain Injury Association?					
Any specific questions?

Other Questions or Concerns
This is the end of the questionnaire. Thank you for taking the time to provide us with this information.
Staff Names and Signatures
Date	Time	Print Name	Signature	Title	Initials