| RPT |
.|.|Neurobehavioral Symptom Inventory||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB:
activities. $~
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Questions and Answers||1. Feeling dizzy:| <*Answer_3868*>|2. Loss of balance:| <*Answer_3881*>|3. Poor coordination,
clumsy:| <*Answer_3882*>|4. Headaches:| <*Answer_3883*>|5. Nausea:| <*Answer_3884*>|6. Vision problems, blurring, trouble seeing:| <*Answer_3885*>|7. Sensitivity to light:|
<*Answer_3886*>|8. Hearing difficulty:| <*Answer_3887*>|9. Sensitivity to noise:| <*Answer_3888*>|10. Numbness or tingling on parts of my body:| <*Answer_3889*>|11. Change in taste and/or
smell:| <*Answer_3890*>|12. Loss of appetite or increase appetite:| <*Answer_3891*>|13. Poor concentration, can't pay attention, easily distracted:| <*Answer_3892*>|14. Forgetfulness, can't
remember things:| <*Answer_3893*>|15. Difficulty making decisions:| <*Answer_3894*>|16. Slowed thinking, difficulty getting organized, can't finish things:| <*Answer_3895*>|17. Fatigue, loss
of energy, getting tired easily:| <*Answer_3896*>|18. Difficulty falling or staying asleep:| <*Answer_3897*>|19. Feeling anxious or tense:| <*Answer_3898*>|20. Feeling depressed or sad:|
<*Answer_3900*>|21. Irritability, easily annoyed:| <*Answer_3901*>|22. Poor frustration tolerance, feeling easily overwhelmed by things:| <*Answer_3902*>||Information contained in this note is
based on a self report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic
|
