| RPT |
|Traumatic Brain Injury: 2nd Level Evaluation||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB:
toxic fumes, or crush injuries from structures falling onto you? | <*Answer_4107*>|5d4a. Distance to blast: (Indicate the closest episode)| <*Answer_4108*>|5d5. Type of blast exposures: (Check
all that apply)| <*Answer_4109*>|5e. Other causes of injury: (Were you injured during your deployment in any other way?)| <*Answer_4110*>|6. Did you lose consciousness immediately after any of
these experiences?| <*Answer_4111*>|6a. What was the longest duration of unconsciousness?| <*Answer_4112*>|7. Did you have a period of disorientation or confusion immediately following the
incident?| <*Answer_4113*>|7a. What was the duration of longest period of alteration of consciousness?| <*Answer_4114*>|8. Did you experience a period of memory loss immediately before or after
the incident?| <*Answer_4115*>|8a. What was the duration of longest period of memory loss?| <*Answer_4116*>|9. During this/these experience(s), did an object penetrate your skull/cranium:|
<*Answer_4117*>|10. Were you wearing a helmet at the time of most serious injury?| <*Answer_4118*>|11. Were you evacuated from theatre?| <*Answer_4119*>|12. Prior to this evaluation, had you
received any professional treatment (including medications) for your deployment related TBI symptoms?| <*Answer_4120*>|12a. Have you ever been prescribed medications for symptoms related to your
deployment related TBI symptoms?| <*Answer_4121*>|13. Prior to your OEF/OIF deployment, did you experience a brain injury or concussion?| <*Answer_4122*>|14. Since your OEF/OIF deployment, have
you experienced a brain injury or concussion?| <*Answer_4123*>|15. Since the time of your deployment related injury/injuries, has anyone told you that you were acting differently?|
<*Answer_4124*>|16a. Feeling Dizzy:| <*Answer_4125*>|16b. Loss of balance:| <*Answer_4126*>|16c. Poor coordination, clumsy:| <*Answer_4127*>|16d. Headaches:| <*Answer_4128*>|16e. Nausea:|
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||1. Current marital status:| <*Answer_4091*>|2. Highest level of educational achievement:| <*Answer_4092*>|3. Current
<*Answer_4129*>|16f. Vision problems, blurring, trouble seeing:| <*Answer_4130*>|16g. Sensitivity to light:| <*Answer_4131*>|16h. Hearing difficulty:| <*Answer_4132*>|16i. Sensitivity to
noise:| <*Answer_4133*>|16j. Numbness or tingling in parts of my body:| <*Answer_4134*>|16k. Change in ability to taste and/or smell:| <*Answer_4135*>|16l. Loss of appetite or increase
appetite:| <*Answer_4136*>|16m. Poor concentration, can't pay attention:| <*Answer_4137*>|16n. Forgetfullness, can't remember things:| <*Answer_4138*>|16o. Difficutly making decisions:|
<*Answer_4139*>|16p. Slowed thinking, difficulty getting organized, can't finish things:| <*Answer_4140*>|16q. Fatigue, loss of energy, getting tired easily:| <*Answer_4141*>|16r. Difficulty
falling or staying asleep:| <*Answer_4142*>|16s. Feeling anxious or tense:| <*Answer_4143*>|16t. Felling depressed or sad:| <*Answer_4144*>|16u. Irritability, easily annoyed:|
<*Answer_4145*>|16v. Poor frustration tolerance, feeling easily overwhelmed by things:| <*Answer_4146*>|17. Overall, in the last 30 days how much did these difficulties (symptoms?) interfere with
your life?| <*Answer_4147*>|17a. In what areas of your life are you having difficulties because of these symptoms?| <*Answer_4148*>|18. In the last 30 days, have you had any problems with
pain?| <*Answer_4149*>|18a. Location of pain: (Check all that apply)| <*Answer_4150*>|18a1. Other:| <*Answer_4151*>|18b. In the last 30 days, how much did pain interfere with your life?|
<*Answer_4152*>|18c. In what areas of your life are you having difficulties because of pain?| <*Answer_4153*>|19. Since the time of your deployment related injury/injuries, are your overall
symptoms:| <*Answer_4154*>|20. Psychiatric Symptoms:| <*Answer_4155*>|20a. Psychiatric disorder:| <*Answer_4156*>|21. SCI:| <*Answer_4157*>|22. Amputation:| <*Answer_4158*>|23. Other
employment status:| <*Answer_4093*>|4a. First Date (Oldest injury, MM/DD/YYYY):| <*Answer_4094*>|4b. Second date:| <*Answer_4095*>|4c. Third date:| <*Answer_4096*>|5a. Bullet:|
significant medical conditions/problems:| <*Answer_4159*>|24. Are the findings consistent with diagnosis of TBI ?| <*Answer_4160*>|25. Follow up plan:| <*Answer_4161*>|25a. Education:|
<*Answer_4162*>|25b. Consult requested with: (Check all that apply)| <*Answer_4163*>|25c. Referral to Polytrauma Network Site (PNS):| <*Answer_4164*>|25d. Electro diagnostic study (nerve
conduction / electromyogram):| <*Answer_4165*>|25e. Lab:| <*Answer_4166*>|25f. Head CT:| <*Answer_4167*>|25g. Brain MRI:| <*Answer_4168*>|25h. Other Consultation:| <*Answer_4169*>|25i.
New medication trial or change in dose of existing medication:| <*Answer_4170*>|25i1. Specify other:| <*Answer_4171*>|26. Other information (use for additional History of Present Illness,
Social History, Patient Goals, Details of Plan, etc.):| <*Answer_4172*>| $~
<*Answer_4097*>|5b. Vehicular:| <*Answer_4098*>|5c. Fall:| <*Answer_4099*>|5d. Blast:| <*Answer_4100*>|5d1. When a high-explosive bomb or IED goes off there is a "blast wave" which is a wave
of highly compressed gas that may feel almost like being smashed into a wall. Do you remember experiencing this or were told that you experienced it? | <*Answer_4101*>|5d1a. Distance to blast:
(Indicate the closest episode)| <*Answer_4102*>|5d2. This "blast wave" is followed by a wind in which particles of sand, debris, shrapnel, and fragments are moving rapidly. Were you close enough
to the blast to be "peppered" or hit by such debris,shrapnel, or other items? | <*Answer_4103*>|5d2a. Distance to blast: (Indicate the closest episode)| <*Answer_4104*>|5d3. Were you thrown to
the ground or against some stationary object, like a wall or vehicle, by the explosion? This is not asking if you "ducked to the ground" to protect yourself.| <*Answer_4105*>|5d3a. Distance to
blast: (Indicate the closest episode)| <*Answer_4106*>|5d4. Did you experience any of the following injuries as a result of an explosive blast: burns, wounds, broken bones, amputations, breathing
|
