AMS hr / min / sec AMS hr / min / sec AMS hr / min / sec PTA hr / min / sec PTA hr / min / sec PTA hr / min / sec LOC LOC LOC hr / min / sec hr / min / sec hr / min / sec Severity If Mild: Severity If Mild: Severity If Mild: Mild Stage I Mild Stage I Mild Stage I Moderate Stage II Moderate Stage II Moderate Stage II Severe III Severe Stage III Severe Stage III BATL BATL Score (0 BATL Score (0 5) 5) (0 5) – – – Nature of Blast Nature of Blast Nature of Primary (Head) Primary (Head) Primary (Head) Secondary (Head: Yes No) Secondary (Head: Yes No) Secondary (Head: Yes No) Tertiary (Head: Yes No) Tertiary (Head: Yes No) Tertiary (Head: Yes No) Quaternary (Head: Yes No) Quaternary (Head: Yes No) Quaternary (Head: Yes No) MILITARY OTHER: # Other TBIs: 1st Most Severe 2nd Most Severe 3rd Most Severe Age Age Age AMS AMS AMS hr / min / sec hr / min / sec hr / min / sec PTA hr / min / sec PTA hr / min / sec PTA hr / min / sec LOC hr / min / sec LOC hr / min / sec LOC hr / min / sec Severity If Mild: Severity If Mild: Severity If Mild: Mild Stage I Mild Stage I Mild Stage I Moderate Stage II Moderate Stage II Moderate Stage II Severe Stage III Severe Stage III Severe Stage III BATL Score BATL Score (0 BATL Score (0 5) 5) (0 5) – – – Nature of Injury Nature of Injury Nature of Injury MVA Physical Assault MVA Physical Assault MVA Physical Assault Fall Penetrating Injury Fall Penetrating Injury Fall Penetrating Injury Sports- Other: Sports- Other: Sports- Other: Related Related Related PRE-MILITARY: # TBIs:
AMS hr / min / sec AMS hr / min / sec AMS hr / min / sec PTA hr / min / sec PTA hr / min / sec PTA hr / min / sec LOC hr / min / sec LOC hr / min / sec LOC hr / min / sec Severity If Mild: Severity If Mild: Severity If Mild: Mild Stage I Mild Stage I Mild Stage I Moderate Stage II Moderate Stage II Moderate Stage II Severe III Severe Stage III Severe Stage III BATL (0 – 5) BATL Score (0 – 5) BATL Score (0 – 5) Nature of Blast Nature of Blast Nature of Primary (Head) Primary (Head) Primary (Head) Secondary (Head: Yes No) Secondary (Head: Yes No) Secondary (Head: Yes No) Tertiary (Head: Yes No) Tertiary (Head: Yes No) Tertiary (Head: Yes No) Quaternary (Head: Yes No) Quaternary (Head: Yes No) Quaternary (Head: Yes No) MILITARY OTHER: # Other TBIs: 1st Most Severe 2nd Most Severe 3rd Most Severe Age Age Age AMS hr / min / sec AMS hr / min / sec AMS hr / min / sec PTA hr / min / sec PTA hr / min / sec PTA hr / min / sec LOC hr / min / sec LOC hr / min / sec LOC hr / min / sec Severity If Mild: Severity If Mild: Severity If Mild: Mild Stage I Mild Stage I Mild Stage I Moderate Stage II Moderate Stage II Moderate Stage II Severe Stage III Severe Stage III Severe Stage III BATL Score (0 – 5) BATL Score (0 – 5) BATL Score (0 – 5) Nature of Injury Nature of Injury Nature of Injury MVA Physical Assault MVA Physical Assault MVA Physical Assault Fall Penetrating Injury Fall Penetrating Injury Fall Penetrating Injury Sports- Related Other: Sports- Related Other: Sports- Related Other: PRE-MILITARY: # TBIs:
JHTR_1_1_2013_02_01_FORTIER_1_SDC1.docx