| RPT |
|Neurobehavioral Symptom Inventory for Traumatic Brain Injury (NSI FOR TBI)
| Gender: <.Patient_Gender.>
|
| NSI Subscales
| Cognitive subscale = <-Cognitive subscale->
| Mood-Behavioral subscale = <-Mood-Behavioral subscale->
| Vestibular - Sensory subscale = <-Vestibular - Sensory subscale->
|
|
|Questions and Answers:
|
|
| 1. Feeling dizzy
| <*Answer_7771*>
| 2. Loss of balance
| <*Answer_7772*>
| 3. Poor coordination, clumsy
| <*Answer_7773*>
| 4. Headaches
| <*Answer_7774*>
| 5. Nausea
| <*Answer_7775*>
| Date Given: <.Date_Given.>
| 6. Vision problems, blurring, trouble seeing
| <*Answer_7776*>
| 7. Sensitivity to light
| <*Answer_7777*>
| 8. Hearing difficulty
| <*Answer_7778*>
| 9. Sensitivity to noise
| <*Answer_7779*>
| 10. Numbness or tingling on parts of my body
| <*Answer_7780*>
| Clinician: <.Staff_Ordered_By.>
| 11. Change in taste and/or smell
| <*Answer_7781*>
| 12. Loss of appetite or increased appetite
| <*Answer_7782*>
| 13. Poor concentration, can't pay attention, easily distracted
| <*Answer_7783*>
| 14. Forgetfulness, can't remember things
| <*Answer_7784*>
| 15. Difficulty making decisions
| <*Answer_7785*>
| Location: <.Location.>
| 16. Slowed thinking, difficulty getting organized, can't finish things
| <*Answer_7786*>
| 17. Fatigue, loss of energy, getting tired easily
| <*Answer_7787*>
| 18. Difficulty falling or staying asleep
| <*Answer_7788*>
| 19. Feeling anxious or tense
| <*Answer_7789*>
| 20. Feeling depressed or sad
| <*Answer_7790*>
|
| 21. Irritability, easily annoyed
| <*Answer_7791*>
| 22. Poor frustration tolerance, feeling easily overwhelmed by things
| <*Answer_7792*>
|
|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 activities.
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
