Part Three: head injury Did you experience any of the following? YES NO DATE ........... ........... ........… Drowning Suffocation Blow to the head Did you lose consciousness? If yes, for how long were you unconscious? (tick as applicable) Less than 30 minutes 30-60 minutes 60-120 minutes more than 120 minutes Part Four: Present State of Health Questionnaire The following questions describe the client’s possible present state of health. Read each one carefully and ask the client to describe how much the symptoms have bothered him or her in the past week. YES (1) Headache (2) Dizziness (3) Impaired concentration (4) Impairment of memory (5) Impairment of hearing (6) Numbness or pins and needles in arms/legs (7) Reduced strength in arms or legs (8) Pains in shoulders or arms (9) Pains in legs, including feet (10) Backache (11) Chest pain (12) Palpitations (13) Abdominal pains (14) Nausea (15) Vomiting (16) Diarrhoea (17) Constipation (18) Pain on urination (19) Male pain in the genitals, female pelvic pain (20) Lacking control on urination or defaecation (21) Convulsions or loss of consciousness in the last month (22) Menstrual disturbances If "yes", circle by number: 1. Absence of menstrual periods 2. Too frequent periods 3. Bleeding between periods 4. Very heavy bleeding during periods State duration of disturbances in months................ (23) Sleep disturbances NO