| RPT |
.|.|Comprehensive Traumatic Brain Injury Evaluation||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB:
or other items? | <*Answer_3932*>| | 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 the ground" to protect yourself).| <*Answer_3933*>| | 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_3934*>| | 5-D-5. Type of blast exposures: (Check all that apply)|
<*Answer_3935*>| | 5-E. Blunt trauma other than from blast/vehicular injury, e.g., assault, blunt force, sports related or object hitting head.| <*Answer_3936*>||6. Did you lose
consciousness immediately after any of these experiences?| <*Answer_3937*>| | 6-A. If yes, estimate the duration of longest period of loss of consciousness.| <*Answer_3943*>||7. Did you
have a period of disorientation or confusion immediately following the incident?| <*Answer_3944*>| | 7-A. If yes, estimate the duration of longest period of disorientation or confusion.|
<*Answer_3945*>||8. Did you experience a period of memory loss immediately before or after the incident?| <*Answer_3947*>| | 8-A. If yes, estimate the duration of longest period of memory loss
(Post Traumatic Amnesia (PTA)).| <*Answer_3956*>||9. During this/these experience(s), did an object penetrate your skull/cranium:| <*Answer_3957*>||10. Were you wearing a helmet at the time of
most serious injury?| <*Answer_3958*>||11. Were you evacuated from theatre?| <*Answer_3960*>||12. Prior to this evaluation, had you received any professional treatment (including medications)
for your deployment related TBI symptoms?| <*Answer_3961*>| | 12-A. Have you ever been prescribed medications for symptoms related to your deployment related TBI symptoms?|
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||Questions and Answers||A. Was this evaluation furnished by a non-VA provider, e.g., fee basis?| <*Answer_3906*>||1. Current
<*Answer_3964*>||13. Since the time of your deployment related injury/injuries, has anyone told you that you were acting differently?| <*Answer_3965*>||14. Prior to your OEF/OIF deployment, did
you experience a brain injury or concussion?| <*Answer_3969*>||15. Since your OEF/OIF deployment, have you experienced a brain injury or concussion?| <*Answer_3970*>||II. SYMPTOMS||16.
Neurobehavioral Symptoms:| Please rate the following symptoms with regard to how they have affected you over the past 30 days. Use the following scale:| None 0 - Rarely if ever present; not a
problem at all| Mild 1 - Occasionally present, but it does not disrupt activities; I can usually continue what I am doing; does not really concern me.| Moderate 2 - Often present, occasionally
disrupts my activities; I can usually continue what I am doing with some effort; I am somewhat concerned.| Severe 3 - Frequently present and disrupts activities; I can only do things that are
fairly simple or take little effort; I feel like I need help.| Very Severe 4 - Almost always present and I have been unable to perform at work, school, or home due to this problem; I probably cannot
function without help.|| 16-A. Feeling dizzy: <*Answer_3971*>| 16-B. Loss of balance: <*Answer_3988*>| 16-C. Poor coordination, clumsy: <*Answer_3990*>| 16-D. Headaches:
<*Answer_3991*>| 16-E. Nausea: <*Answer_3992*>| 16-F. Vision problems, blurring, trouble seeing: <*Answer_3993*>| 16-G. Sensitivity to light: <*Answer_3994*>| 16-H. Hearing difficulty:
<*Answer_3995*>| 16-I. Sensitivity to noise: <*Answer_3996*>| 16-J. Numbness or tingling in parts of my body: <*Answer_3997*>| 16-K. Change in ability to taste and/or smell:
<*Answer_3998*>| 16-L. Loss of appetite or increase appetite: <*Answer_3999*>| 16-M. Poor concentration, can't pay attention: <*Answer_4000*>| 16-N. Forgetfulness, can't remember things:
marital status:| <*Answer_3908*>||2. Pre-military level of educational achievement:| <*Answer_3909*>||3. Current employment status:| <*Answer_3916*>||I. INJURY||4. How many serious OEF/OIF
<*Answer_4001*>| 16-O. Difficulty making decisions: <*Answer_4002*>| 16-P. Slowed thinking, difficulty getting organized, can't finish things: <*Answer_4003*>| 16-Q. Fatigue, loss of energy,
getting tired easily: <*Answer_4007*>| 16-R. Difficulty falling or staying asleep: <*Answer_4008*>| 16-S. Feeling anxious or tense: <*Answer_4009*>| 16-T. Feeling depressed or sad:
<*Answer_4010*>| 16-U. Irritability, easily annoyed: <*Answer_4011*>| 16-V. Poor frustration tolerance, feeling easily overwhelmed by things: <*Answer_4012*>||17. Overall, in the last 30 days
how much did these difficulties (symptoms) interfere with your life?| <*Answer_4013*>| | 17-A. In what areas of your life are you having difficulties because of these symptoms?|
<*Answer_4014*>||III. PAIN||18. In the last 30 days, have you had any problems with pain?| <*Answer_4017*>| | 18-A. Location of pain: (Check all that apply)| <*Answer_4018*>|| 18-B. In
the last 30 days, how much did pain interfere with your life?| <*Answer_4020*>| | 18-C. In what areas of your life are you having difficulties because of pain?| <*Answer_4021*>||19. Since the
time of your deployment related injury/injuries, are your overall symptoms:| <*Answer_4023*>||IV. CONCLUSION||20. Additional history of present illness, social history, functional history, patient
goals, and other relevant information.| <*Answer_4024*>||21. Current medication:| <*Answer_4025*>||22. Physical Examination:| <*Answer_4026*>||23. Psychiatric Symptoms:| <*Answer_4027*>|
| 23-A. If yes or suspected/probable, symptoms of which disorders?| <*Answer_4028*>||24. SCI:| <*Answer_4029*>||25. Amputation:| <*Answer_4030*>||26. Other significant medical
conditions/problems:| <*Answer_4031*>||V. DIAGNOSIS||27. Are the history of the injury and course of clinical symptoms consistent with a diagnosis of TBI sustained during OEF/OIF deployment?|
deployment related injuries have occurred?| <*Answer_3917*>| | 4-A-1. Month of most serious injury: <*Answer_3918*>| 4-A-2. Year of most serious injury: <*Answer_3919*>| | 4-B-1.
<*Answer_4032*>||28. In your clinical judgment the current clinical symptom presentation is most consistent with:| <*Answer_4034*>| | 28-A. Specify other condition(s):| <*Answer_4044*>||VI.
PLAN||29. Follow up plan:| <*Answer_4045*>|| 29-A. Education:| <*Answer_4046*>|| 29-B. Consult requested with: (Check all that apply)| <*Answer_4047*>|| 29-C. Referral to Polytrauma
Network Site (PNS):| <*Answer_4048*>|| 29-D. Electro diagnostic study (nerve conduction / electromyogram):| <*Answer_4049*>|| 29-D-1. Electroencephalogram (EEG):| <*Answer_4050*>||
29-E. Lab:| <*Answer_4051*>|| 29-F. Head CT:| <*Answer_4052*>|| 29-G. Brain MRI:| <*Answer_4053*>|| 29-H. Other Consultation:| <*Answer_4054*>|| 29-I. New medication trial or
change in dose of existing medication to address the following symptoms:| <*Answer_4055*>|| 29-I-1. Other symptom(s):| <*Answer_4086*>||30. Details of Plan:| <*Answer_4087*>||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 and procedures.| | $~
Month of second serious injury: <*Answer_3920*>| 4-B-2. Year of second serious injury: <*Answer_3921*>| | 4-C-1. Month of least serious injury: <*Answer_3922*>| 4-C-2. Year of least
serious injury: <*Answer_3923*>||5. Cause of Injury:| 5-A. Bullet: <*Answer_3924*>| | 5-B. Vehicular: <*Answer_3925*>| | 5-C. Fall: <*Answer_3926*>| | 5-D. Blast:
<*Answer_3927*>| | 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_3928*>| | 5-D-1-a. Estimated distance from closest blast: <*Answer_3929*>| | 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,
|
