| RPT |
.|.|Traumatic Brain Injury: Follow-Up Assessment||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB:
the ground" to protect yourself.)| <*Answer_5034*>| 5-D-4. Did you experience any of the following injuries as a result of an explosive blast: burns, wounds, broken bones, amputations,
breathing toxic fumes, or crush injuries from structures falling onto you? | <*Answer_5036*>| 5-D-5. Type of blast exposures: (Check all that apply)| <*Answer_5038*>| 5-E. Blunt trauma
other than from blast/vehicular injury, e.g., assault, blunt force or object hitting head| <*Answer_5230*>||6. Did you lose consciousness immediately after any of these experiences?|
<*Answer_5040*>| 6-A. If yes, estimate the duration of longest period of loss of consciousness?| <*Answer_5041*>||7. Did you have a period of disorientation or confusion immediately following
the incident?| <*Answer_5042*>| 7-A. If yes, estimate the duration of longest period of disorientation or confusion.| <*Answer_5043*>||8. Did you experience a period of memory loss
immediately before or after the incident?| <*Answer_5044*>| 8-A. If yes, estimate the duration of longest period of memory loss (Post Traumatic Amnesia (PTA))| <*Answer_5045*>||9. During
this/these experience(s), did an object penetrate your skull/cranium:| <*Answer_5046*>||10. If you have had a new injury, have you seen any health care providers (doctors/therapists) as a result
of the new head injury?| <*Answer_5492*>| 10-A. Did the provider you saw for your new injury change your medications in any way (new type or change in dosage)?| <*Answer_5493*>||11. Please
rate the following symptoms with regard to how they have affected you over the past 30 days.| 11-A. Feeling Dizzy:| <*Answer_5047*>| 11-B. Loss of balance:| <*Answer_5048*>| 11-C. Poor
coordination, clumsy:| <*Answer_5049*>| 11-D. Headaches:| <*Answer_5050*>| 11-E. Nausea:| <*Answer_5051*>| 11-F. Vision problems, blurring, trouble seeing:| <*Answer_5052*>| 11-G.
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>|||A. Chief Complaint:| <*Answer_5018*>|B. History of Present Illness, or Interval History since last visit|
Sensitivity to light:| <*Answer_5053*>| 11-H. Hearing difficulty:| <*Answer_5054*>| 11-I. Sensitivity to noise:| <*Answer_5055*>| 11-J. Numbness or tingling in parts of my body:|
<*Answer_5056*>| 11-K. Change in ability to taste and/or smell:| <*Answer_5057*>| 11-L. Loss of appetite or increase appetite:| <*Answer_5058*>| 11-M. Poor concentration, can't pay
attention:| <*Answer_5059*>| 11-N. Forgetfullness, can't remember things:| <*Answer_5060*>| 11-O. Difficutly making decisions:| <*Answer_5061*>| 11-P. Slowed thinking, difficulty
getting organized, can't finish things:| <*Answer_5062*>| 11-Q. Fatigue, loss of energy, getting tired easily:| <*Answer_5063*>| 11-R. Difficulty falling or staying asleep:|
<*Answer_5064*>| 11-S. Feeling anxious or tense:| <*Answer_5065*>| 11-T. Feeling depressed or sad:| <*Answer_5066*>| 11-U. Irritability, easily annoyed:| <*Answer_5067*>| 11-V. Poor
frustration tolerance, feeling easily overwhelmed by things:| <*Answer_5068*>||12. Overall, in the last 30 days how much did these difficulties (symptoms?) interfere with your life?|
<*Answer_5069*>| 12-A. In what areas of your life are you having difficulties because of these symptoms?| <*Answer_5070*>||13. In the last 30 days, have you had any problems with pain?|
<*Answer_5071*>| 13-A. Location of pain: (Check all that apply)| <*Answer_5072*> | 13-B. In the last 30 days, how much did pain interfere with your life?| <*Answer_5074*>| 13-C. In what
areas of your life are you having difficulties because of pain?| <*Answer_5075*>||14. Since your last evaluation, are your overall symptoms:| <*Answer_5076*>|15. Additional comments regarding
current symptoms/functional status:| <*Answer_5077*>|16. System Review:| <*Answer_5078*>|17. Physical Exam:| <*Answer_5079*>|18. Current medications:| <*Answer_5080*>|19. Professional
<*Answer_5019*>||1. Change in Marital Status:| <*Answer_5020*>||2. Highest educational level achieved:| <*Answer_5021*>| 2-A. Current school or training status:| <*Answer_5022*>||3.
conclusion/assessment:| <*Answer_5081*>||20. Has the patient experienced a new TBI since their last diagnosis?| <*Answer_5082*>| 20-A. In your clinical judgment the current clinical symptom
presentation is most consistent with:| <*Answer_5231*>||21. Follow up plan: (Check all that apply)| <*Answer_5084*>|22. Details of plan:| <*Answer_5085*>| | The information contained in
note created from the template for a TBI Follow up Evaluation, and may only contain a portion of the full evaluation. A full TBI Follow Up Evaluation contains a history of patient's present
illness/symptoms, focused review of body systems, targeted physical exam, confirming the diagnosis of TBI, and a follow up/treatment plan. Full follow up evaluation documentation should be attached
to this note via an addendum if the free text boxes in the template were not utilized to capture this information. $~
Current employment status:| <*Answer_5023*>||4. Experienced head injury since prior evaluation?| <*Answer_5024*>| 4-A. Month of most recent head injury:| <*Answer_5228*>| 4-B. Year of
most recent head injury:| <*Answer_5229*>||5. Cause of injury: | 5-A. Bullet| <*Answer_5026*>| 5-B. Vehicular:| <*Answer_5027*>| 5-C. Fall:| <*Answer_5028*>| 5-D. Blast:|
<*Answer_5029*>| 5-D-1. 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_5030*>| 5-D-1-A. Estimated distance from closest blast:| <*Answer_5031*>| 5-D-2. 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_5032*>| 5-D-3. Were you thrown to the ground or against some stationary object like a wall, vehicle or inside a vehicle by the explosion? (This is not asking if you "ducked to
|
