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TBI-1 PATIENT INFORMATION/HISTORY FORM Institute of Neurological Recovery 100 UCLA Medical Plaza Suites 205-210 Los Angeles CA 90095 361 Hospital Road Suite 428 Newport Beach CA 92663 PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS TO THE BEST OF YOUR ABILITY. ALL INFORMATION WILL REMAIN CONFIDENTIAL. Potential patient or caregiver may fill this form out. I. POTENTIAL PATIENT INFORMATION Name First Today s Date Mid. Init. Last Home Address City/Stat.

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4 Types of Brain Injuries and 3 Levels of Severity Mild Traumatic Brain Injury. A mild TBI generally does not cause a loss of consciousness. ... Moderate Traumatic Brain Injury. ... Severe Traumatic Brain Injury. ... Concussion. ... Penetrating Brain Injuries. ... Anoxic Brain Injuries and Contusions. ... Diffuse Axonal Injury.

2023 ICD-10-CM Diagnosis Code S06. 301A: Unspecified focal traumatic brain injury with loss of consciousness of 30 minutes or less, initial encounter.

ICD-10 code S06. 300 for Unspecified focal traumatic brain injury without loss of consciousness is a medical classification as listed by WHO under the range - Injury, poisoning and certain other consequences of external causes .

Other Conditions Linked to TBI Post-traumatic stress disorder (PTSD) Depression. Sleep apnea. Migraine headaches.

ICD-10 Code for Personal history of traumatic brain injury- Z87. 820- Codify by AAPC.

TBI diagnostic code: S06.

Typical approaches to determining severity early after injury include neuroimaging, assessing the presence of an altered consciousness or loss of consciousness, assessing the presence of posttraumatic amnesia, and applying the Glasgow Coma Scale score.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232