For the Veteran or Servicemember claimant diagnosed with a TBI, you should specifically address the history of each symptom, or residual, as described in the documentation protocol. Since individuals with TBI may have difficulty organizing and communicating their symptoms without prompting, it is important to ask about and document all problems, whether subtle or pronounced, so that the Veteran or Servicemember can be appropriately evaluated for all disabilities associated with TBI. You must address each one of the signs or symptoms and report the findings in as much detail as necessary. Negative, as well as, positive responses to residual symptoms should be documented. Ask what types of treatments have been used and whether they have been effective.
You may need to complete additional documentation protocols as you evaluate residuals in the examination:
- motor dysfunction
- sensory dysfunction
- hearing loss and/or tinnitus
- visual impairments
- alteration of sense of smell or taste
- seizures
- gait, coordination, and balance
- speech (including aphasia and dysarthria)
- neurogenic bladder
- neurogenic bowel
- cranial nerve dysfunction
- skin disorders
- endocrine dysfunction