Head Injury
Onset [text] prior to evaluation
Onset while: [text]
Injury at: [text]

Impact at [text]
[select value="no|YES"] <-- nasal drainage/bleeding
[select value="no|YES"] <-- ear drainage/bleeding

Associated Pain (0=none, 10=severe)
Location: [text]
Radiation: [text]
Severity now (0-10): [text]
Severity at worst (0-10): [text]
Duration: [text]
Characterized as [text].

[select value="no|YES"] <-- remembers the accident
[select value="no|YES"] <-- remembers after the accident

Episode was witnessed by [text] and they reported:
[select value="no|YES"] <-- complete loss of consciousness for a duration of [text]
[select value="no|YES"] <-- Seizure activity
[select value="no|YES"] <-- Confusion following the episode
[select value="no|YES"] <-- associated incontinence of urine or stool

Episode was followed by the following symptoms that lasted [text]:
[select value="no|YES"] <-- headache
[select value="no|YES"] <-- neck pain
[select value="no|YES"] <-- lightheadedness
[select value="no|YES"] <-- extremity weakness
[select value="no|YES"] <-- Vision change
[select value="no|YES"] <-- Hearing change
[select value="no|YES"] <-- nausea or vomiting
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: contributed by Dr. Scott Moses, creator/author of the Family Practice Notebook [link url="//www.fpnotebook.com" memo="(link)"][/conditional]