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Evidence checklist

Traumatic Brain Injury (TBI)

DC 804538 CFR § 4.124aNeurological

Evidence strength

Mark what you already have below and your evidence strength appears here.

Target
Saved locally
01

Specialist opinion

Highest value0 of 4 collected
Neuropsychological testing documenting cognitive deficitsCritical

A comprehensive neuropsychological battery documenting memory, attention, processing speed, and executive function deficits. VA raters use these results to assess cognitive impairment level under 38 CFR § 4.124a DC 8045.

Private provider · independent opinion
MRI or CT brain imaging showing structural changesCritical

Neuroimaging documenting contusions, diffuse axonal injury, encephalomalacia, or other TBI-related structural changes. A normal scan does not preclude a rating — include a radiologist report.

Private provider · independent opinion
Nexus opinion linking TBI to in-service event ("at least as likely as not")Critical

A medical opinion connecting your TBI to a documented in-service event such as blast exposure, vehicle accident, or direct head trauma.

Private provider · independent opinion
Neurologist or physiatrist evaluation of TBI residualsCritical

A current evaluation documenting all TBI residuals including headaches, dizziness, sleep disturbance, mood changes, and cognitive symptoms — all of which contribute to the overall TBI rating.

Private provider · independent opinion
02

Treatment records

0 of 1 collected
TBI treatment and rehabilitation records

Records from TBI clinic, occupational therapy, speech therapy, cognitive rehabilitation, or other TBI-focused treatment documenting functional status.

VA or private records · written request
03

Lay statements

0 of 2 collected
Buddy statement from spouse, family, or fellow service member

A written statement from someone who can describe observable symptoms and how your condition affects daily life.

You or a witness · VA Form 21-4138 or 21-10210How to get this →
Personal statement describing symptoms and functional impact

Your own written account of how this condition affects your daily activities, work, and relationships. Describe your worst days.

You or a witness · VA Form 21-4138 or 21-10210How to get this →
04

Benefits questionnaire

0 of 1 collected
Completed DBQ Traumatic Brain InjuryCritical

VA standardized form specifically for TBI that captures cognitive symptoms, neurobehavioral effects, and functional impact across all rating facets.

Provider-completed · VA DBQ formHow to get this →
05

Service records

0 of 2 collected
In-service incident documentation (LOD, SIRS report, medical records)Critical

Line of Duty determination, Significant Incident Report, or medical records documenting the head injury event during service.

NPRC / milConnect · SF-180
Service treatment records (STRs)Critical

Military medical records showing in-service treatment, complaints, or injuries related to this condition.

NPRC / milConnect · SF-180
Condition guideRating criteria and what VA looks forC&P exam prepWhat the examiner will askBuddy statement builderGuided VA Form 21-10210

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