Brain Injury Association of PEI Survey
The Brain Injury Association of Prince Edward Island (BIAPEI) is a non-profit organization dedicated to promoting and contributing to an environment supportive to the brain injury community, and to providing awareness & prevention of brain injury in PEI.

We are conducting a survey of people living on PEI who have experienced concussions, or who have a brain injury, whether as a result of a stroke, illness or accident. All answers and information will be held in confidence and are anonymous. They will be used to provide statistical data, which will be beneficial to improving access to services, long term care, and will be useful to health care policy makers.

Your assistance helps us in identifying the needs of people living in PEI. We thank you for your time.

We ask that only one survey be filled out per person.

If you would prefer to fill out a hard copy, have any questions, or would like assistance in filling out the survey, please contact us at info@biapei.com, (902) 314-4228 or (902) 367-3216.
Date Complete: *
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Postal Code: *
Your answer
Age: *
Your answer
Gender:
Your answer
Is someone helping you fill out this survey? *
Do you have a primary care giver? *
Have you ever had a concussion? *
If you have had one or more concussions, please list the year(s) in which they occurred.
Your answer
Have you ever been knocked unconscious? *
If you have ever been knocked unconscious, for how long were you unconscious?
Your answer
Have you ever been diagnosed/told you have a brain injury? *
If you have a brain injury, when did you first acquire it, or when were you first diagnosed?
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How did you obtain your injury?
In the first month after your injury or diagnosis, were you seen by the following, with regards to your brain injury *
check all that apply
Required
Do you have problems with any of the following *
Always or Often
Occasionally
Rarely or Never
Short Term Memory
Long Term Memory
Ability to learn new things
Vision
Hearing
Dizziness
Making decisions
Solving problems
Pain
Walking
Focus/Paying Attention
Balance
Sleep
Anxiety
Depression
Mood Swings
Lack of energy
Feeling emotionally exhausted
Feeling physically exhausted
Interacting with other people
Bowel or Urinary problems
Do you have problems with anything not mentioned that affects your life?
please list
Your answer
Are you currently on any medications to help with the above symptoms, or related to your injury? *
If yes, do you have a health practitioner following up with you with regards to the effectiveness of the medication?
Have you increased your use of the following as a way of coping with your injury? *
Ocassionally
Moderately
Frequently
Heavily
Not Applicable
Alcohol
Non-Prescription Marijuana
Non-Prescription painkillers or muscle relaxants
Prescription painkillers
Prescription relaxation medication
Other prescription medication
Other non-prescription medication
Do you currently see any of the following with regards to your brain injury? *
check all that apply
Required
Are there any of the following that you wish you were seeing with regards to your brain injury? *
check all that apply
Required
Have you ever been admitted to any of the following departments? *
check all that apply, with regards to your injury
Required
Do you currently work or go to school? *
Required
Since having a brain injury, have you ever been arrested? *
Have you ever received any of the following diagnostic procedures? *
check all that apply
Required
What best describes your living situation? *
Have you ever had to leave the province for care related to your brain injury? *
If yes, for what?
Your answer
If yes, where did you have to travel to?
Please list the hospital/clinic, or the city and province.
Your answer
How many times have you had to leave the province for care related to your brain injury?
Your answer
Do you feel like the services offered to you in PEI are adequate, and meet your needs? *
why or why not?
Your answer
What services relating to brain injury do you feel should be more accessible in PEI? *
Your answer
What services do you feel are adequate or meet your needs relating to your brain injury? *
Your answer
Do you currently attend a support group for brain injury survivors? *
Do you think a support group is/would be beneficial? *
Your answer
Do you know where to go to access information with regards to support in PEI? *
If there is anything else you'd like to add, please say it here.
Your answer
If you would be willing to be contacted by our researcher to provide further information on your personal experience, please provide your name and contact information (phone number or e-mail address) below.
Leave this blank if you do not wish to be contacted.
Your answer
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