DATE:           TIME (24hr): 

TBI Second Level Evaluation - MIND STUDY Form

1Current Marital Status
2Pre-Military Education
3Current Employment Status
4Date(s) of most serious OEF/OIF deployment related injuries. Month/Year.
4a1st:  
4b2nd: 
4c3rd: 
5Injury etiology (all that apply)
5aNumber of episodes:
5bNumber of episodes: 
5cNumber of episodes:
5dNumber of episodes:

*** Complete the following question 5 subsections, only if blast is selected above
*** (see Blast Exposure Assessment below)
5d1A Blast Primary (When a high explosive bomb or IED goes off there is a "blast wave" which is a wave of highly compressed gas that hits solid objects like a person’s body and may feel almost like smashing into a wall.) 
Did you remember experiencing this type of "blast wave" or were told that you experienced it?
Number of blasts in which this occurred Distance from closest blast
5d2B. Blast Secondary (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?
Number of blasts in which this occurred 
5d3C. Blast Tertiary
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).
Number of blasts in which this occurred 
5d4D. Blast Quaternary
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?
Number of blasts in which this occurred 
5d5Type of blast exposures (all that apply)
5e
Number of episodes:
6Did you lose consciousness immediately after any of these experiences?
If yes, number of occurrences
If yes, duration of longest period of loss of consciousness
7aDid you experience a period of disorientation or confusion immediately following the incident?
If yes, number of occurrences
If yes, duration of longest period of disorientation or confusion
7bDid you experience a period of memory loss immediately before or after the incident?
If yes, number of occurrences
If yes, duration of longest period of Post Traumatic Amnesia (PTA)
8During this / these experience(s), did an object penetrate your skull/cranium: 
9Were you wearing a helmet at the time of most serious injury?
10Were you evacuated from theatre?
11Prior to this evaluation, had you received any professional treatment (including medications) for your deployment related TBI symptoms?
11a(only if 11 is yes) Have you ever been prescribed medications for symptoms related to your deployment related TBI symptoms?
12Prior to your OEF/OIF deployment, did you experience a brain injury or concussion? 
13Since you returned from your OEF/OIF deployment, have you experienced a brain injury or concussion?
14Since the time of your deployment related injury/injuries, has anyone told you that you were acting differently?
15 Please rate the following symptoms with regard to how much 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'm doing; doesn't really concern me.
Moderate 2 - Often present, occasionally disrupts my activities;  I can usually continue what I'm 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
NoneMildModerateSevereVery
Severe
15aFeeling Dizzy   
15bLoss of balance 
15cPoor Coordination, clumsy 
15dHeadaches 
15eNausea 
15fVision problems, blurring, trouble seeing 
15gSensitivity to light 
15hHearing difficulty 
15iSensitivity to noise 
15jNumbness or tingling on parts of my body 
15kChange in taste and/or smell 
15lLoss of appetite or increase appetite 
15mPoor concentration, can't pay attention 
15nForgetfulness, can't remember things 
15oDifficulty making decisions 
15pSlowed thinking, difficulty getting organized, can't finish things 
15qFatigue, loss of energy, getting tired easily 
15rDifficulty falling or staying asleep 
15sFeeling anxious or tense 
15tFeeling depressed or sad 
15uIrritability, easily annoyed 
15vPoor frustration tolerance, feeling easily overwhelmed by things 

16Overall, in the last 30 days how much did these difficulties (symptoms) interfere with your life?
16aIn what areas of your life are you having difficulties because of these symptoms? 

17
Pain
17aIn the last 30 days, have you had any problems with pain?
If yes, location(s) (check all that apply)
if other:  
17bIf yes, in the last 30 days, how much did pain interfere with your life?
17cIn what areas of your life are you having difficulties because of pain?
18Since the time of your deployment related injury/injuries, are your overall symptoms:

OTHER INFORMATION
Additional history of present illness, social history, functional history, patient goals, and other relevant information
Current medications
Physical Examination

PROFESSIONAL CONCLUSION/ASSESSMENT
19Psychiatric Symptoms 
19aIf yes or suspected/probable, symptoms of which disorders?
20SCI
21Amputation
Amputation Classification
 
22Other significant medical conditions/problems 
23

Are the history of the injury and course of clinical symptoms consistent with a diagnosis of TBI sustained during OEF/OIF deployment?

23aIn your clinical judgment the current clinical symptom presentation is most consistent with:

PLAN
24Follow up plan

Follow up Care within the VA (check all that apply)
24a 
24b
24c
24d 
24d 
24e
24f
24g
24h
24i
if other: