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Caregiver Survey
TBI Identification Cards
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Indicates required field
AHIF recognizes that interactions between TBI survivors and First Responders can, at times, lead to issues of misunderstanding. To assist in communicating your unique situation as a TBI Survivor, AHIF is pleased to provide a free TBI Identification Card. Just complete the submit your answers to the questions below, and we will send you your personalized card.
How would you like your name to be listed?
*
Who is your Emergency Contact?
*
What is your relationship to your emergency contact?
*
Parent
Son
Daughter
Spouse
Other
What is your Emergency Contact's phone number?
*
What is most important for someone to know about you as a result of your injury? (Please check the three (3) most important items
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I might respond slowly to questions
I might get confused from multiple questions at once
My eyes might not focus on you while you are speaking to me
I might have an unsteady walk
I might become agitated or upset
I might not be able to stand or walk
I might need instructions repeated more than once
I often am overstimulated by loud sounds and/or bright lights
Other
If you selected "Other," please specify
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How would you recommend someone to most effectively communicate with you? (Please choose up to four options)
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Speak slowly and clearly
Pause periodically to ask me if I understand
Be prepared to repeat yourself
Be patient with me, because it might take me a moment to respond
Do not ask too many questions at once
Other
If you selected "Other," please specify
*
Please Enter the Address You Would Like Your Card Mailed To Below
*
Thank you for taking time to complete this questionnaire. We will send your card to you as quickly as possible!
Submit