51 (51)    MH REPORT (601.93)

.|.|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,