Head Impact and Trauma (HIT) & Blast Overpressure (BOP) Self-Assessment

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Head Impact and Trauma (HIT) & Blast Overpressure (BOP) Self-Assessment

Head Impact and Trauma (HIT) & Blast Overpressure (BOP) Self-Assessment

*The Brain Keeps Score®*

For decades, we’ve addressed the psychological wounds of law enforcement and first responders without asking a critical question: Are there underlying neurological factors?

I created this HIT (Head Impact Trauma) and BOP (Blast Overpressure) Self-Assessment to confront what has long been ignored. Repeated exposure to head impacts—from defensive tactics, firearms instruction, breaching, combatives, and training scenarios—can alter the brain. This isn’t limited to combat injuries; it includes the cumulative trauma faced by military, law enforcement and other first responders by simply doing their jobs.

It is my belief that the presence of neurological comorbidities is the missing piece in suicide prevention. If you’ve experienced symptoms of PTSD, depression, anxiety, or impulsivity—and you’ve worn a badge, served in the military, or trained others in high-impact environments—you need to take this assessment.

We cannot treat what we do not understand. It starts with the brain.

Respectfully,
Stephanie Samuels, MA, MSW, LCSW
Clinician Specializing in Law Enforcement Mental Health Since 1989
Founder, CopLine, Inc.

Why this matters:

Many first responders, military members, and civilians experience head impacts, blasts, or repeated jolts to the body or brain through their work or life experiences—even without losing consciousness. These injuries may not seem serious at the time but can build up and affect memory, emotions, sleep, and behavior later in life. This form helps document those possible exposures so your care team can better understand what might be affecting you.

Name

Enter your email address to receive a copy of your completed form

Date

MM slash DD slash YYYY

Who is filling out this form? (Check all that apply)

Active Police Officer

Retired Police Officer

Special/Auxiliary Police

Active Firefighter

Retired Firefighter

Volunteer Firefighter

EMT/Paramedic

Active Military

Retired Military

Civilian

Other

Who is filling out this form - Other:

 How many years have you served (including full-time, part-time, or volunteer)?

0–5 years

6–10 years

11–15 years

16–20 years

21–25 years

26+ years

Early Life Experiences

Before age 18, were you exposed to any of the following? (Check all that apply—even if it happened only once.)

Shaken or thrown as a baby/toddler

Dropped

Hit in the head

Bullied or attacked

Strangled or choked

Severe neglect or physical abuse

Witness to domestic violence

Severe car accident or fall

Other

Not Applicable

Exposed to any of the following - Other:

Approximate age(s) when this occurred:

1–5

6–10

11–15

16–20

21+

Not Applicable

Questions or Notes about Early Life Experiences:

Accidents, Injuries & Repetitive Impacts

Have you experienced any of the following on or off the job? (Check all that apply)

Motor vehicle crashes

Falls (on stairs, ice, uneven ground, etc.)

Hit by an object (e.g., equipment, tools)

Hard stop in a police cruiser

Bumped your head getting in/out of a vehicle

Street fights or physical altercations

Taken to the ground during an arrest or training

Sucker punched or hit in the face/head

Training accidents

Structural collapse (e.g., falling through ceiling/roof)

Repetitive body or head jarring

Other

Not Applicable

Experienced the following - Other:

Number of Accidents/Injuries:

None

1–5

6–10

11–20

21+

Approximate Age Range(s) When These Occurred:

None

1–5

6–10

11–15

16–30

31+

Contact Sports & Training Impacts

Have you participated in any of the following? (Include department teams or training activities)

Football

Wrestling

Boxing, MMA, or Grappling

Rugby

Hockey (ice/roller/field)

Lacrosse

Soccer

Horseback riding

Defensive tactics training (repetitive impact)

Firearms or simunitions training with close-quarter blasts

Other

Not Applicable

Participated in the following - Other:

Approximate Age(s) When Active:

0–5

6–10

11–15

16–30

31+

Not Applicable

Number of Impacts or Head Injuries During Sports or Training:

None

1–100

101–250

251–500

501–750

751–1000

1000+

Questions or Notes about Contact Sports & Training Impacts:

Military Exposure & Blast Events

Did you serve in the military?

Years Served:

None

1–5

6–10

11–15

16–20

21+

Ages During Service:

17–25

26–35

36–45

46–60

60+

Number of Combat Tours Completed:

None

1–3

4–6

7–9

10+

Were you exposed to any of the following during service?

Breacher (explosives entry)

IED (Improvised Explosive Devices)

50 Caliber weapons

Field Artillery

Aircraft Carrier Vibration

Military Vehicle Vibration

Grenade or RPG detonation

Explosion or Blast nearby

Blunt force trauma to head/body

Military Vehicle Crash

Injured by Fragment or Debris

Airborne Operations (jumps)

Other

Not Applicable

Exposed to any of the following - Other:

SWAT/Tactical Team Roles & Training

Did you serve on a SWAT or Tactical Team?

Years Served:

None

1–5

6–10

11–15

16–20

21+

Role on SWAT or Tactical Team:

Operator/Flashbang

Breacher

Sniper

Shield/Entry

Other

Not Applicable

Role on SWAT or Tactical Team - Other:

Number of Training or Operational Events with Close-Range Blast or Impact:

None

1–25

26–50

51–100

100+

Concussions & Head Impact History

Concussions WITHOUT loss of consciousness (diagnosed or undiagnosed). This could include: getting your bell rung or rocked, seeing stars or shook your head to “reset” as some examples.

None

1–5

6–10

11–15

16–20

21+

Concussions WITH Loss of Consciousness (e.g., blackout, memory loss): (defined as any loss of time, awareness, voluntary control, memory, or responsiveness)

None

1–5

6–10

11–15

16–20

21+

Were you ever officially diagnosed?

Yes

If yes, how many times did you receive treatment?

None

1–3

4–6

7 or more

Questions or Notes about Concussions & Head Impact History:

Post-Concussion & Brain Health Symptoms

Please check off any symptoms you experienced at the time of injury or that you are still experiencing today. Next to each symptom, mark the following status if applicable: 

R = Resolved | S = Same | W = Worse | Leave blank if never experienced.

Physical Symptoms

Headache or 'pressure' in the head

Neck Pain

Light-headedness

Nausea

Vomiting

Dizziness

Sensitivity to light

Sensitivity to sound

Ringing in the ears

Balance problems

Fatigue

Blurred or double vision

Decreased sense of taste or smell

Reduced tolerance to stress, emotional excitement, or alcohol

Other

Physical Symptoms - Other (Describe)

Cognitive Symptoms

Difficulty thinking clearly

Memory loss

Problems planning or organizing

Trouble learning new information

Difficulty with attention or concentration

Mental 'slowness'

Confusion

Other

Cognitive Symptoms - Other (Describe)

Mood and Behavioral Changes

Increased irritability or short temper

Impulsivity

Aggression

Depression or sadness

Anxiety or nervousness

Emotional ups and downs

Lack of motivation or apathy

Personality changes

Substance misuse

Suicidal thoughts or behaviors

Explosive reactions (e.g., outbursts)

Emotional instability

Other

Mood and Behavioral Changes - Other (Describe)

Sleep-Related Symptoms

Sleeping more than usual

Sleeping less than usual

Trouble falling or staying asleep

Interrupted sleep cycle

Nightmares or vivid dreams

Other

Sleep-Related Symptoms - Other (Describe)

Motor Symptoms (If Applicable)

Parkinsonism (tremors, slow movement)

Motor Neuron Disease

Muscle weakness or spasms

Other

Motor Symptoms - Other

Questions or Notes about Motor Symptoms (If Applicable):

Copyright and Use Notice

© 2025 Stephanie Samuels, MA, MSW, LCSW. All rights reserved.

This HIT (Head Impact Trauma) and BOP (Blast Overpressure) Self-Assessment Form and all related materials are the sole intellectual property of Stephanie Samuels, MA, MSW, LCSW.

No portion of this document may be copied, reproduced, distributed, adapted, displayed, published, or otherwise used in any form without the express prior written permission of the copyright holder. This includes, but is not limited to, clinical, educational, training, or commercial use.

Unauthorized use or dissemination is strictly prohibited and may result in legal action under applicable intellectual property laws.

For permissions or inquiries, please contact:

Stephanie Samuels, MA, MSW, LCSW
501 Iron Bridge Rd., Suite 6
Freehold, NJ
Email: ccidc63@gmail.com
Stephanie Samuels