Kitsap Brain Injury Wellness Survey QTR 2
In this part of this questionnaire, we would like to know how satisfied you are with different aspects of your life since your brain injury. For each question, please choose the answer that is closest to how you feel now (including the past week) and mark the selection. If you have problems filling out the questionnaire, please ask for help.

  • A. These questions are about your thinking abilities now (including the past week).
  • Not at all Slightly Moderately Quite Very
    1. How satisfied are you with your ability to concentrate, for example when reading or keeping track of a conversation?
    2. How satisfied are you with your ability to express yourself and understand others in a conversation?
    3. How satisfied are you with your ability to remember everyday things, for example where you have put things?
    4. How satisfied are you with your ability to plan and work out solutions to everyday practical problems, for example, what to do when you lose your keys?
    5. How satisfied are you with your ability to make decisions?
    6. How satisfied are you with your ability to find your way around?
    7. How satisfied are you with your speed of thinking?

  • B. These questions are about your emotions and view of yourself now (including the past week).
  • Not at all Slightly Moderately Quite Very
    1. How satisfied are you with your level of energy?
    2. How satisfied are you with your level of motivation to do things?
    3. How satisfied are you with your self-esteem, how valuable you feel?
    4. How satisfied are you with the way you look?
    5. How satisfied are you with what you have achieved since your brain injury?
    6. How satisfied are you with the way you perceive yourself?
    7. How satisfied are you with the way you see your future?

  • C. These questions are about your independence and how you function in daily life now (including the past week).
  • Not at all Slightly Moderately Quite Very
    1. How satisfied are you with the extent of your independence from others?
    2. How satisfied are you with your ability to get out and about?
    3. How satisfied are you with your ability to carry out domestic activities, for example, cooking or repairing things?
    4. How satisfied are you with your ability to run your personal finances?
    5. How satisfied are you with your participation in work or education?
    6. How satisfied are you with your participation in social and leisure activities, for example sports, hobbies, parties?
    7. How satisfied are you with the extent to which you are in charge of your own life?

  • D. These questions are about your social relationships now (including the past week)
  • Not at all Slightly Moderately Quite Very
    1. How satisfied are you with your ability to feel affection towards others, for example, your partner, family, or friends?
    2. How satisfied are you with your relationships with members of your family?
    3. How satisfied are you with your relationships with your friends?
    4. How satisfied are you with your relationship with a partner or with not having a partner?
    5. How satisfied are you with your sex life?
    6. How satisfied are you with the attitudes of other people towards you?

  • E. These questions are about how bothered you are by your feelings now (including the past week).
  • Not at all Slightly Moderately Quite Very
    1. How bothered are you by feeling lonely, even when you are with other people?
    2. How bothered are you by feeling bored?
    3. How bothered are you by feeling anxious?
    4. How bothered are you by feeling sad or depressed?
    5. How bothered are you by feeling angry or aggressive?

  • F. These questions are about how bothered you are by physical problems now (including the past week)
  • Not at all Slightly Moderately Quite Very
    1. How bothered are you by slowness and/or clumsiness of movement?
    2. How bothered are you by effects of any other injuries you sustained at the same time as your brain injury?
    3. How bothered are you by pain, including headaches?
    4. How bothered are you by problems with seeing or hearing?

  • G. The third part will identify how you feel about your substance use behavior.
  • No Yes
    1. Have you ever had a drinking or other nonprescription drug problem?
    2. Within the last 3 months have you used alcohol or other nonprescription drugs?
    3. Within the last 3 months have you felt that you use too much alcohol or other nonprescription drugs?
    4. Do you feel that you have a drinking or drug problem now?