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National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on the Review of the Department of Veterans Affairs Examinations for Traumatic Brain Injury. Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans. Washington (DC): National Academies Press (US); 2019 Apr 10.

Cover of Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans

Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans.

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DDBQ Initial Evaluation of Residuals of Traumatic Brain Injury (I-TBI) Disability1

Name of Patient/Veteran: ________________________________SSN: __________________

Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits.

VA will consider the information you provide on this questionnaire as part of their evaluation in processing the Veteran's claim.

SECTION I

1. Diagnosis

Does the Veteran now have or has he/she ever had a traumatic brain injury (TBI) or any residuals of a TBI?

  • Image img-s.jpg Yes   Image img-s.jpg No

If yes, select the Veteran's condition (check all that apply):

  • Image img-s.jpg Traumatic brain injury (TBI)   ICD code: _________   Date of diagnosis: _____
  • Image img-s.jpg Other diagnosed residuals attributable to TBI, specify: _________
  • Other diagnosis #1: _________
    ICD code: _________
    Date of diagnosis: _________
  • Other diagnosis #2: _________
    ICD code: _________
    Date of diagnosis: _________
  • Other diagnosis #3: _________
    ICD code: _________
    Date of diagnosis: _________
  • Other diagnosis #4: _________
    ICD code: _________
    Date of diagnosis: ______________

If there are additional diagnoses that pertain to the residuals of a TBI, list using above format: ______________

2. Medical history

a.

Describe the history (including onset and course) of the Veteran's TBI and residuals attributable to TBI (brief summary): ______________________________________

b.

Was the Veteran exposed to any blasts?

  • Image img-s.jpg Yes   Image img-s.jpg No
    If yes, indicate number of blasts:
    Image img-s.jpg 1   Image img-s.jpg 2   Image img-s.jpg 3   Image img-s.jpg More than 3
    Date of first blast exposure: _______________
    Date of last blast exposure: _______________
    How many blasts were severe enough to knock Veteran down or cause injury?
    Image img-s.jpg 0   Image img-s.jpg 1   Image img-s.jpg 2   Image img-s.jpg 3   Image img-s.jpg More than 3
c.

Does the Veteran's treatment plan include taking continuous medication for the diagnosed condition?

  • Image img-s.jpg Yes   Image img-s.jpg No
    If yes, list only those medications used for the diagnosed condition: _________________

3. Evidence review

Was medical evidence available for review as part of this examination?

  • Image img-s.jpg Yes   Image img-s.jpg No
    If yes, indicate evidence reviewed as part of this examination (check all that apply):
    Image img-s.jpg VA claims file (C-file)
    If checked, documents listed separately below that are included in a C-file do not need to be additionally indicated.
    Image img-s.jpg Veterans Health Administration medical records (CPRS treatment records)
    Image img-s.jpg Civilian medical records
    Image img-s.jpg Military service treatment records
    Image img-s.jpg Military service personnel records
    Image img-s.jpg Military enlistment examination
    Image img-s.jpg Military separation examination
    Image img-s.jpg Military post-deployment questionnaire
    Image img-s.jpg Department of Defense Form 214 separation document
    Image img-s.jpg Previous disability decision letters
    Image img-s.jpg Correspondence and non-medical documents related to condition
    Image img-s.jpg Interviews with collateral witnesses (family and others who have known the Veteran before and after military service)
    Image img-s.jpg Medical evidence brought to exam by Veteran
    If checked, describe: ___________________
    Image img-s.jpg Other, describe: ______________________________________

SECTION II. Assessment of cognitive impairment and other residuals of TBI

NOTE: For each of the following 10 facets of TBI-related cognitive impairment and subjective symptoms (facets 1–10 below), select the ONE answer that best represents the Veteran's current functional status.

Neuropsychological testing may need to be performed in order to be able to accurately complete this section. If neuropsychological testing has been performed and accurately reflects the Veteran's current functional status, repeat testing is not required.

1.

Memory, attention, concentration, executive functions

  • Image img-s.jpg No complaints of impairment of memory, attention, concentration, or executive functions.
  • Image img-s.jpg A complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing.
  • Image img-s.jpg Objective evidence on testing of mild impairment of memory, attention, concentration, or executive functions resulting in mild functional impairment.
  • Image img-s.jpg Objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment.
  • Image img-s.jpg Objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment.
    If the Veteran has complaints of impairment of memory, attention, concentration or executive functions, describe (brief summary): ______________________________________________
2.

Judgment

  • Image img-s.jpg Normal
  • Image img-s.jpg Mildly impaired judgment. For complex or unfamiliar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision.
  • Image img-s.jpg Moderately impaired judgment. For complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions.
  • Image img-s.jpg Moderately severely impaired judgment. For even routine and familiar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision.
  • Image img-s.jpg Severely impaired judgment. For even routine and familiar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision. For example, unable to determine appropriate clothing for current weather conditions or judge when to avoid dangerous situations or activities.
    If the Veteran has impaired judgment, describe (brief summary): ___________________
3.

Social interaction

  • Image img-s.jpg Social interaction is routinely appropriate.
  • Image img-s.jpg Social interaction is occasionally inappropriate.
  • Image img-s.jpg Social interaction is frequently inappropriate.
  • Image img-s.jpg Social interaction is inappropriate most or all of the time.
    If the Veteran's social interaction is not routinely appropriate, describe (brief summary):
4.

Orientation

  • Image img-s.jpg Always oriented to person, time, place, and situation.
  • Image img-s.jpg Occasionally disoriented to one of the four aspects (person, time, place, situation) of orientation.
  • Image img-s.jpg Occasionally disoriented to two of the four aspects (person, time, place, situation) of orientation or often disoriented to one aspect of orientation.
  • Image img-s.jpg Often disoriented to two or more of the four aspects (person, time, place, situation) of orientation.
  • Image img-s.jpg Consistently disoriented to two or more of the four aspects (person, time, place, situation) of orientation.
    If the Veteran is not always oriented to person, time, place, and situation, describe (brief summary): _______
5.

Motor activity (with intact motor and sensory system)

  • Image img-s.jpg Motor activity normal.
  • Image img-s.jpg Motor activity is normal most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function).
  • Image img-s.jpg Motor activity is mildly decreased or with moderate slowing due to apraxia.
  • Image img-s.jpg Motor activity moderately decreased due to apraxia.
  • Image img-s.jpg Motor activity severely decreased due to apraxia.
    If the Veteran has any abnormal motor activity, describe (brief summary): ______
6.

Visual spatial orientation

  • Image img-s.jpg Normal
  • Image img-s.jpg Mildly impaired. Occasionally gets lost in unfamiliar surroundings, has difficulty reading maps or following directions. Is able to use assistive devices such as GPS (global positioning system).
  • Image img-s.jpg Moderately impaired. Usually gets lost in unfamiliar surroundings, has difficulty reading maps, following directions, and judging distance. Has difficulty using assistive devices such as GPS (global positioning system).
  • Image img-s.jpg Moderately severely impaired. Gets lost even in familiar surroundings, unable to use assistive devices such as GPS (global positioning system).
  • Image img-s.jpg Severely impaired. May be unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment.
    If the Veteran has impaired visual spatial orientation, describe (brief summary): _______
7.

Subjective symptoms

  • Image img-s.jpg No subjective symptoms.
  • Image img-s.jpg Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family or other close relationships. Examples are: mild or occasional headaches, mild anxiety.
  • Image img-s.jpg Three or more subjective symptoms that mildly interfere with work; instrumental activities of daily living; or work, family or other close relationships. Examples of findings that might be seen at this level of impairment are: intermittent dizziness, daily mild to moderate headaches, tinnitus, frequent insomnia, hypersensitivity to sound, hypersensitivity to light.
  • Image img-s.jpg Three or more subjective symptoms that moderately interfere with work; instrumental activities of daily living; or work, family or other close relationships. Examples of findings that might be seen at this level of impairment are: marked fatigability, blurred or double vision, headaches requiring rest periods during most days.
    If the Veteran has subjective symptoms, describe (brief summary): ______
8.

Neurobehavioral effects

NOTE: Examples of neurobehavioral effects of TBI include: irritability, impulsivity, unpredictability, lack of motivation, verbal aggression, physical aggression, belligerence, apathy, lack of empathy, moodiness, and lack of cooperation, inflexibility, and impaired awareness of disability. Any of these effects may range from slight to severe, although verbal and physical aggression are likely to have a more serious impact on workplace interaction and social interaction than some of the other effects.

  • Image img-s.jpg No neurobehavioral effects.
  • Image img-s.jpg One or more neurobehavioral effects that do not interfere with workplace interaction or social interaction.
  • Image img-s.jpg One or more neurobehavioral effects that occasionally interfere with workplace interaction, social interaction, or both but do not preclude them.
  • Image img-s.jpg One or more neurobehavioral effects that frequently interfere with workplace interaction, social interaction, or both but do not preclude them.
  • Image img-s.jpg One or more neurobehavioral effects that interfere with or preclude workplace interaction, social interaction, or both on most days or that occasionally require supervision for safety of self or others.
    If the Veteran has any neurobehavioral effects, describe (brief summary): ______
9.

Communication

  • Image img-s.jpg Able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language.
  • Image img-s.jpg Comprehension or expression, or both, of either spoken language or written language is only occasionally impaired. Can communicate complex ideas.
  • Image img-s.jpg Inability to communicate either by spoken language, written language, or both, more than occasionally but less than half of the time, or to comprehend spoken language, written language, or both, more than occasionally but less than half of the time. Can generally communicate complex ideas.
  • Image img-s.jpg Inability to communicate either by spoken language, written language, or both, at least half of the time but not all of the time, or to comprehend spoken language, written language, or both, at least half of the time but not all of the time. May rely on gestures or other alternative modes of communication. Able to communicate basic needs.
  • Image img-s.jpg Complete inability to communicate either by spoken language, written language, or both, or to comprehend spoken language, written language, or both. Unable to communicate basic needs.
    If the Veteran is not able to communicate by or comprehend spoken or written language, describe (brief summary): ___________________________
10.

Consciousness

  • Image img-s.jpg Normal
  • Image img-s.jpg Persistent altered state of consciousness, such as vegetative state, minimally responsive state, coma.
    If checked, describe altered state of consciousness (brief summary):

SECTION III

1.

Residuals

Does the Veteran have any subjective symptoms or any mental, physical, or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease)?

  • Image img-s.jpg Yes   Image img-s.jpg No

If yes, check all that apply:

  • Image img-s.jpg Motor dysfunction
    If checked, ALSO complete specific Joint or Spine Questionnaire for the affected joint or spinal area.
  • Image img-s.jpg Sensory dysfunction
    If checked, ALSO complete appropriate Cranial or Peripheral Nerve Questionnaire.
  • Image img-s.jpg Hearing loss and/or tinnitus
    If checked, ALSO complete a Hearing Loss and Tinnitus Questionnaire.
  • Image img-s.jpg Visual impairment
    If checked, ALSO complete an Eye Questionnaire.
  • Image img-s.jpg Alteration of sense of smell or taste
    If checked, ALSO complete a Loss of Sense of Smell and Taste Questionnaire.
  • Image img-s.jpg Seizures
    If checked, ALSO complete a Seizure Disorder Questionnaire.
  • Image img-s.jpg Gait, coordination, and balance
    If checked, ALSO complete appropriate Questionnaire for underlying cause of gait and balance disturbance, such as Ear Questionnaire.
  • Image img-s.jpg Speech (including aphasia and dysarthria)
    If checked, ALSO complete appropriate Questionnaire.
  • Image img-s.jpg Neurogenic bladder
    If checked, ALSO complete appropriate Genitourinary Questionnaire.
  • Image img-s.jpg Neurogenic bowel
    If checked, ALSO complete appropriate Intestines Questionnaire.
  • Image img-s.jpg Cranial nerve dysfunction
    If checked, ALSO complete a Cranial Nerves Questionnaire.
  • Image img-s.jpg Skin disorders
    If checked, ALSO complete a Skin and/or Scars Questionnaire.
  • Image img-s.jpg Endocrine dysfunction
    If checked, ALSO complete an Endocrine Conditions Questionnaire.
  • Image img-s.jpg Erectile dysfunction
    If checked, ALSO complete Male Reproductive Conditions Questionnaire.
  • Image img-s.jpg Headaches, including Migraine headaches
    If checked, ALSO complete a Headache Questionnaire.
  • Image img-s.jpg Meniere's disease
    If checked, ALSO complete an Ear Conditions Questionnaire.
  • Image img-s.jpg Mental disorder (including emotional, behavioral, or cognitive)
    If checked, ALSO complete Mental Disorders or PTSD Questionnaire.
  • Image img-s.jpg Other, describe: __________________
    If checked, ALSO complete appropriate Questionnaire.
2.

Other pertinent physical findings, scars, complications, conditions, signs and/or symptoms

a.

Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above?

  • Image img-s.jpg Yes   Image img-s.jpg No
    If yes, are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)?
  • Image img-s.jpg Yes   Image img-s.jpg No
    If yes, also complete a Scars Questionnaire.
b.

Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms?

  • Image img-s.jpg Yes   Image img-s.jpg No
    If yes, describe (brief summary): _________________________
3.

Diagnostic testing

NOTE: If diagnostic test results are in the medical record and reflect the Veteran's current TBI residuals, repeat testing is not required.

a.

Has neuropsychological testing been performed?

  • Image img-s.jpg Yes   Image img-s.jpg No
    If yes, provide date: _________________________
    Results: ___________________________________
b.

Have diagnostic imaging studies or other diagnostic procedures been performed?

  • Image img-s.jpg Yes   Image img-s.jpg No
    If yes, check all that apply:
  • Image img-s.jpg Magnetic resonance imaging (MRI)
    Date: ___________ Results: ______________
  • Image img-s.jpg Computed tomography (CT)
    Date: Results:
  • Image img-s.jpg ___________ ______________ EEG
    Date: ___________ Results: ______________
  • Image img-s.jpg Other, describe:
    Date: ___________ Results: ______________
c.

Has laboratory testing been performed?

  • Image img-s.jpg Yes   Image img-s.jpg No
    If yes, specify tests: Date: ___________ Results: ______________
d.

Are there any other significant diagnostic test findings and/or results?

  • Image img-s.jpg Yes   Image img-s.jpg No
    If yes, provide type of test or procedure, date and results (brief summary): ___________
4.

Functional impact

Do any of the Veteran's residual conditions attributable to a traumatic brain injury impact his or her ability to work?

  • Image img-s.jpg Yes   Image img-s.jpg No
    If yes, describe impact of each of the Veteran's residual conditions attributable to a traumatic brain injury, providing one or more examples: _____________________
5.

Remarks, if any:

  • Physician signature: __________________________________________ Date: _____________
  • Physician printed name: _______________________________________
  • Medical license #: _____________
  • Physician address: __________________________
  • Phone: ________________________ Fax: ________________________

NOTE: The VA may request additional medical information, including additional examinations if necessary to complete the VA's review of the veteran's application.

Footnotes

1
Copyright 2019 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK542603

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