Neurological

Traumatic Brain Injury (TBI) C&P Exam Guide

Associated DBQ Form: DBQ TBI

What to Expect During Your Exam

The TBI C&P exam is comprehensive, typically lasting 60-90 minutes. It involves cognitive testing, neurological examination, and detailed symptom assessment.

The exam includes:
1. Review of the traumatic event(s)
2. Cognitive assessment (memory, concentration, processing speed)
3. Neurological examination
4. Assessment of physical, emotional, and cognitive symptoms
5. Review of imaging studies (CT, MRI)

Questions the Examiner May Ask

  • 1 Describe the event(s) that caused your TBI
  • 2 Did you lose consciousness? For how long?
  • 3 Were you disoriented or confused after the event?
  • 4 Do you have memory problems?
  • 5 Do you have difficulty concentrating?
  • 6 Do you experience headaches?
  • 7 Are you sensitive to light or noise?
  • 8 Have you noticed personality changes?
  • 9 Do you have balance problems or dizziness?
  • 10 How does TBI affect your work performance?

Documentation to Bring

  • Service treatment records documenting the TBI event
  • Records showing loss of consciousness or altered mental status
  • Brain imaging (CT, MRI)
  • Neuropsychological testing results
  • Current treatment records
  • Buddy statements about the event and your symptoms
  • Documentation of cognitive rehabilitation

How to Prepare

Before your exam:

1. **Document the event** - Be prepared to describe exactly what happened

2. **Note all symptoms** - Memory issues, headaches, mood changes, balance problems, sleep issues

3. **Track cognitive difficulties** - Examples of memory lapses, concentration problems, word-finding difficulties

4. **List functional impacts** - How does TBI affect work, relationships, daily tasks?

5. **Gather witness statements** - People who knew you before and after can describe changes

Helpful Tips

- TBI is rated based on 10 different facets of impairment
- Be specific about what happened during the traumatic event
- Describe ALL current symptoms, even seemingly minor ones
- Memory and concentration problems are common - give specific examples
- Mention emotional/behavioral changes (irritability, depression, anxiety)
- Headaches related to TBI can sometimes be rated separately
- If you have multiple TBI events, describe each one
- Cognitive testing during the exam is important - do your best but be honest

Common Mistakes to Avoid

- No documented head injury during service
- Claiming loss of consciousness with no medical documentation
- Performing well on cognitive tests while claiming severe impairment
- Inconsistencies between reported symptoms and observed function

How VA Rates This Condition

TBI is rated under 38 CFR § 4.124a, Diagnostic Code 8045, based on three main areas:

**Cognitive Impairment:**
- Memory, concentration, executive function
- Rated 0-70%

**Emotional/Behavioral Dysfunction:**
- Rated under mental health criteria

**Physical Dysfunction:**
- Headaches, balance issues, etc.
- Rated under relevant diagnostic codes

**Overall Rating:** Uses the highest level of impairment across 10 facets:
- Memory/Concentration/Executive Function
- Judgment
- Social Interaction
- Orientation
- Motor Activity
- Visual Spatial Orientation
- Subjective Symptoms
- Neurobehavioral Effects
- Communication
- Consciousness

Each facet is scored 0-3, and ratings range from 0% to 100%.