Citation Nr: 18125095 Decision Date: 08/09/18 Archive Date: 08/08/18 DOCKET NO. 16-03 329 DATE: August 9, 2018 ORDER New and material evidence has been received to reopen a claim of entitlement to service connection for residuals of acne; the claim is reopened and the appeal is allowed to this extent. Service connection for scarring as a residual of acne is granted. New and material evidence has been received to reopen a claim of entitlement to service connection for residuals of encephalitis; the claim is reopened and the appeal is allowed to this extent. Entitlement to service connection for bilateral hearing loss disability is denied. Entitlement to service connection for tinnitus is denied. REMANDED Entitlement to service connection for bilateral knee disability is remanded. Entitlement to service connection for a heart disability (claimed as atrial fibrillation) is remanded. Entitlement to service connection for encephalitis is remanded. FINDINGS OF FACT 1. In an unappealed April 2011 rating decision, the RO denied service connection for residuals of acne. 2. New and material evidence has been received to reopen the claim of entitlement to service connection for residuals of acne. 3. Resolving reasonable doubt in the Veteran’s favor, acne scarring is at least as likely as not related to acne in service. 4. In an unappealed April 2011 rating decision, the RO denied service connection for encephalitis and/or residuals of encephalitis. 5. New and material evidence has been received to reopen the claim of entitlement to service connection for residuals of encephalitis. 6. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of bilateral hearing loss disability. 7. The preponderance of the evidence is against finding that the Veteran has bilateral hearing loss disability due to a disease or injury in service, to include exposure to aircraft. 8. The preponderance of the evidence is against finding that the Veteran has tinnitus due to a disease or injury in service, to include exposure to aircraft. CONCLUSIONS OF LAW 1. Evidence received since the April 2011 RO decision that denied service connection for residuals of acne, which was the last final denial with respect to this issue, is new and material; the claim is reopened. 38 U.S.C. §§ 1154 (a), 5108, 7105; 38 C.F.R. § 3.156, 20.200. 2. The criteria for service connection for acne scarring of the face are met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. Evidence received since the April 2011 RO decision that denied service connection for encephalitis residuals, which was the last final denial with respect to this issue, is new and material; the claim is reopened. 38 U.S.C. §§ 1154 (a), 5108, 7105; 38 C.F.R. § 3.156, 20.200 4. The criteria for service connection for bilateral hearing loss disability are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307,3.309, 3.385. 5. The criteria for service connection for tinnitus are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307,3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from October 1954 to April 1962, and periods of Reserve service between November 1977 and November 1990. These matters come before the Board of Veterans’ Appeals (Board) from an April 2014 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Phoenix, Arizona. In April 2018, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The record was held open for 60 days and the Veteran agreed to waive RO consideration of any newly received evidence (see Board hearing transcript, page 20). The Veteran’s service treatment records (STRs) were damaged in a 1973 fire at the National Personnel Records Center, but they were not destroyed. Copies have been associated with the claims file. After a review of the evidence submitted in association with the Veteran’s claims to re-open the previously denied claims, the Board finds that new and material evidence has been received (e.g. articles, testimony, dermatology memorandum); therefore, the claims to reopen the Veteran’s claims for service connection for residuals of acne and encephalitis are reopened. Service Connection Legal Criteria Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff’d per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Service connection may also be awarded on a presumptive basis for certain chronic diseases, to include hearing loss and tinnitus (an organic disease of the nervous system), listed in 38 C.F.R. § 3.309(a), that manifest to a degree of 10 percent within one year of service separation. Id. §§ 3.303(b), 3.307. Service connection may be awarded on the basis of continuity of symptomatology for those conditions listed in 38 C.F.R. § 3.309(a) if a claimant demonstrates (1) that a condition was noted during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); 38 C.F.R. § 3.303(b). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran’s service as shown by such Veteran’s service record, the official history of each organization in which such Veteran served, such Veteran’s medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154(a). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Entitlement to service connection for residuals of acne. The Veteran contends that he has facial scars from acne in service. The Board concludes, for the reasons noted below, that the Veteran has a current diagnosis of scarring as a residual of acne that began in service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The Veteran’s October 1954 Report of Medical Examination for entrance purposes is negative for any facial scarring or acne. The Veteran testified at the 2018 Board hearing that while he was in service, he began to have acne on his face which he testified was “really bad”. The Veteran’s STRs support that he had chronic acne in service. The STRs reflect that he was seen on April 13, 1956 for moderate acne of the face. He was again seen on April 16, 1956 for an infected cyst on the ear, and again on April 18, 1956. A May 7, 1956 STRs noted that the Veteran’s condition had improved but he was prescribed medication and ultra violet treatment for the face. On May 22, 1956, his condition had again improved and he was to continue his treatment. He was again seen on May 31, 1956, at which time it was noted that improvement continued and the treatment was to continue. A July 6, 1956 entry on a MDW Form No. 132-4 appears to reflect a comment with regard to acne. A July 25, 1956 STR reflects “acne vulgaris chronic – refer to dermatology.” Another notation as to “acne vulgaris” was made on February 28, 1957. Thus, the STRs adequately support that the Veteran had moderate chronic acne which required treatment in service. The Veteran’s June 1977 Report of Medical History for Reserve entrance purposes reflects that he had a history of acne but “no acute problem.” A June 1981 Report of Medical History for Reserve purposes reflects that the Veteran had acne scarring. An April 1985 Report of Medical History for Reserve purposes reflects that the Veteran reported that he had had acne as a teen but none since then. There are no treatment records noting acne between the Veteran’s 1962 separation from active service and the 1981 notation as to scarring. Moreover, the Veteran denied post service acne. A June 2014 memorandum from S. McCarthy (Dermatologist) reflects that the Veteran had “residual mild rolling acne scarring on his cheeks that has most likely resulted from his acne in the past.” The Board acknowledges that a March 2011 VA examination report found no active acne or scars on the head, face, or neck, and instead found “dry and wrinkled skin to his face.” However, as scarring was noted in 1981 and as “mild” scarring was noted in 2014, the Board finds that, in giving the benefit of the doubt to the Veteran, he has residual scarring from acne in service. Entitlement to service connection for bilateral hearing loss disability The Veteran contends that he has bilateral hearing loss disability related to service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000 and 4,000 Hertz is 40 decibels or greater; or when the thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran filed a claim for service connection for bilateral hearing loss disability in September 2013. At that time, he also submitted a Report of Hearing Evaluation which included an audiogram. The audiogram did not reflect that the Veteran met the criteria for a hearing loss disability for VA purposes. The September 9, 2013 evaluation revealed that pure tone air thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 25 25 30 30 LEFT 25 25 25 30 30 The 2013 record also reflects that the NU-6 word list, rather than the VA required Maryland CNC word list was used to evaluate speech recognition. The Veteran underwent another audiology examination in June 2018. The   evaluation revealed that pure tone air thresholds, in decibels, were as follows HERTZ 500 1000 2000 3000 4000 RIGHT 15 25 15 20 20 LEFT 20 20 20 20 25 Speech recognition scores using the Maryland CNC word list were 100 percent for the right ear and 96 percent for the left ear. The Board concludes that the Veteran does not have a current diagnosis of bilateral hearing loss for VA purposes and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as difficulty hearing soft voices. To this extent, the Board finds that the Veteran is competent to report noticeable difficulty with hearing. However, the specific issue in this case, the presence of a hearing loss disability pursuant to 38 C.F.R. § 3.385, is based on objective findings and falls outside the realm of common knowledge of a lay person. Audiometric and word recognition testing is needed to properly assess and diagnose the disorder. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Because the Veteran does not have an auditory threshold of 40 decibels or greater in any of the frequencies of 500, 1,000, 2,000, 3,000 and 4,000 Hertz, does not have an auditory threshold of 26 decibels or greater for at least three of these frequencies, and/or does not have speech recognition scores using the Maryland CNC Test which are 94 percent, he does not meet the criteria for a VA disability. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Entitlement to service connection for tinnitus The Veteran’s STRs are negative for tinnitus. His 1962 Report of Medical History for separation (discharge) reflects that he denied any ear trouble. His June 1977 Report of Medical History for entrance into the Reserves reflects that he denied ear trouble and hearing loss. His June 1981 Report of Medical History (4 year physical for Reserve purposes) and his April 1985 Report of Medical History (4 year physical for Reserve purposes) also both reflect that he denied ear trouble and denied hearing loss. The Veteran testified at the 2018 Board hearing that when he “started getting those bells and whistles”, he reported it. The Veteran’s earliest report of tinnitus is in 2013. The 2013 audio evaluation report reflects that the Veteran asserted that he had intermittent tinnitus; no onset date was listed. Based on the Veteran’s testimony that when he started getting tinnitus, he reported it, and his denials of ear trouble and lack of documentation of tinnitus complaints in service, it can be reasonably found that he did not have tinnitus in service or within one year of separation. The Veteran also testified that he could not state when his tinnitus began but stated that it has been “years” and sometime in between his active duty (which ended in 1962) and 2013 when he was seen by audiology. He also testified that it’s “always been sort of there.” The Board finds that there is no competent credible evidence that the Veteran’s tinnitus began in service or was aggravated by service. The earliest report of tinnitus is in 2013, more than four decades after separation from active service, and more than 20 years after separation from Reserve service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). To the extent the Veteran may be asserting continuity of symptomatology from service, any such statements would be inconsistent with his other statement of record that he could not recall when his tinnitus began. In making such a credibility finding, the Board is not finding that the Veteran has any intent to deceive. Rather, he would simply be mistaken in his recollections due to the fallibility of human memory for events that occurred many years ago. In this regard, the Board notes that with regard to his claim for service connection for residuals of acne, the Veteran testified that he had not been treated for acne in service. However, the STRs, contemporaneous to service, actually do show such treatment on at least eight occasions. While the Veteran may believe that he has tinnitus related to an in-service injury, event, or disease, including working near or on aircraft, he is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In sum, the STRs are negative for tinnitus and reflect that the Veteran denied hearing loss and ear trouble, the earliest report of tinnitus is not for several decades after separation from active service when it was noted to be intermittent, the Veteran has not been able to specify an onset date but has indicated it was years after service (i.e. when it started he reported it in 2013), and there is not competent credible evidence, based on an accurate history, that the Veteran’s current tinnitus is casually related to, or aggravated by, active service. The Board concludes that the preponderance of the evidence weighs against finding that the Veteran’s tinnitus began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d), 3.307, 3.309. REASONS FOR REMAND Entitlement to service connection for bilateral knee disability is remanded. The Veteran contends that he has a bilateral knee disability caused by serving on active duty, to include jumping off aircraft ramps and jumping in and out of trucks. He does not allege any specific injury or treatment in service (see 2013 statement). The Veteran’s STRs are negative for complaints of the knees. His 1962 Report of Medical Examination reflects that he reported a past history of several disabilities but that he did not report knee complaints, and “denied” all that he did not specifically report. He also specifically denied a trick or locked knee, or bone, joint or other deformity or lameness. He reported that his health was “very good”. The Veteran also denied problems in a June 1977 Report of Medical History and noted his health was “good”. He again denied problems in a June 1981 Report of Medical History and noted that his health was “excellent”, and again denied problems in an April 1985 Report of Medical History wherein he also noted that his health was “very good.” The earliest clinical evidence of a knee complaint or disability is more than thirty years after separation from active service. A January 1996 radiology report reflects degenerative changes in the right knee; however, the left knee was unremarkable. A February 2000 private progress note reflects that that the Veteran was obese and that his obesity “ties into his other illnesses”; it was noted that he was taking various supplements for his knees. A January 2001 radiology report reflects bilateral knee DJD. A December 2007 private record (Kaiser Permanente) reflects that the Veteran reported that he had “past multiple minor injuries to ankle, knees, hips from army and football”. An October 2013 health record reflects the statement of the provider as follows “Long-standing degenerative arthritis from over 30 years in active military service. I feel this is service related.” The Board finds that this opinion lacks significant probative value as it is based on an incorrect factual history; the Veteran did not have more than 30 years of active military service. Rather, he had approximately seven and a half years of active service, and approximately 13 years of Reserve service. Moreover, the record does not reflect that the provider had reviewed the Veteran’s STRs. While the October 2013 opinion is not sufficient upon which to base service-connection, it is sufficient to warrant obtaining a clinical opinion based on an accurate factual history. McLendon v. Nicholson, 20 Vet. App.79, 81 (2006). Entitlement to service connection for a heart disability is remanded. The Veteran testified at the April 2018 Board hearing that while in the Reserves, he had applied to go on active duty for Operation Desert Shield, was activated, and was sent for a physical examination. He contends that a heart murmur was found and he was taken “off orders”. He contends that his diagnosis of a heart murmur was the term for atrial fibrillation at the time and that his TDY (temporary duty) orders to go to Desert Storm had already been approved (see Board hearing transcript, page 11). The Veteran’s military personnel records reflect that he was separated from active duty in 1962, and thereafter, had periods of Reserve Inactive duty training (INACTDUTRA) and active duty for training (ACDUTRA) between November 1977 and November 1990. These periods of ACDUTRA averaged approximately two weeks a year with the exception of four weeks between November 1987 and November 1988. The claims file includes a September 23, 1990 Application for Active Duty Training and Annual Training For Members of the Army Reserve, and notes that a temporary tour of active duty had been requested to support Desert Shield. An October 18, 1990 Medical Screening Summary – CardioVascular Risk Screening Program record reflects “Abn” under “Electrocardiogram”, but that the Veteran’s risk did not exceed primary screen limits, and that under the applicable criteria, he should be cleared for the Army’s Physical Fitness training and testing Program. Service connection may be warranted for a disease incurred or aggravated during a period of active duty for training under 38 C.F.R. § 3.6. Based on the current evidence, the Board is unsure if the Veteran had a disability during a period of ACDUTRA, if so, whether it was as likely as not incurred during a period of ACDUTRA, and if he has had a chronic disability since 1990. The claims file includes February 2014 correspondence from Dr. P McGregor in which he states, in pertinent part, as follows: [The Veteran] was diagnosed with atrial fibrillation incidentally around 1990. It is possible that this condition may have existed prior to his diagnosis since he had no symptoms and was diagnosed incidentally. This opinion is of little probative value as one can infer from it that the Veteran’s disability began prior to a period of Reserve service. It also fails to provide any information regarding a time frame of onset. The Board finds that further development may be useful to the Board. As the Veteran had limited ACDUTRA between 1977 and 1990, the exacts dates may be useful in determining whether a disability was actually incurred (and not merely diagnosed) while on ACDUTRA (or active duty.) Thus, VA should attempt to obtain the Veteran’s MMPA (Master Military Pay Account). Additionally, all pertinent clinical records between November 2013, when the Veteran filed his claim, to present should be associated with the claims file to determine when the current disability of atrial fibrillation was diagnosed. The Veteran contends that he has been treated for his heart condition at David Grant Medical Center at Travis Air Force Base. (See November 2013 VA Form 21-4138). In this regard, the Board notes that clinical records do not indicate chronic atrial fibrillation since 1990. June 1996 Kaiser Permanente records reflect that the Veteran had diagnosis of hypertension and was taking Zestril but are negative for other possible cardiac related diagnoses. Kaiser Permanente records in 2001 list 12 diagnoses under the Veteran’s “Problem list” but do not list atrial fibrillation. Records in 2005 note diabetes, hypertension, peripheral neuropathy, a history of colon cancer, peripheral vascular disease, OA of the knees and hands, obesity, and GERD but are negative for atrial fibrillation or other heart disease. VA records in 2013 list more than 40 chronic problems but do not list atrial fibrillation or a murmur. A February 2014 record notes atrial fibrillation. After clinical records have been obtained, a clinical opinion should be obtained. Entitlement to service connection for residuals of encephalitis is remanded. The Veteran’s STRs reflect that he was admitted to the hospital in August 1959 after reporting to the dispensary with a temperature of 103.4 and complaints of a headache. The notation reads “pos encephalitis”. The Veteran has submitted articles on encephalitis which list possible residuals, to include tremors. The Veteran contends that he has residuals of headaches, upper and lower extremity body tremors, chronic fatigue, whole body weakness, and anemia. He also contends that his past encephalitis may cause his mood disorders. The Veteran has not been shown to be competent to provide an etiology for his claimed disabilities, and the Board notes that he has been diagnosed with several nonservice-connected disabilities to include peripheral vascular disease, diabetes, and peripheral neuropathy. The Board also notes that any statement as to continuity of symptoms since 1959 is less than credible given the lack of symptoms noted in the STRs, and given his Reports of Medical History which note that the Veteran reported his health was very good (February 1962), good (June 1977), excellent (June 1981), and very good (April 1985). In addition, an April 2000 Kaiser Permanente Adult Intake/Diagnostic Summary record reflects that the Veteran denied current or past headaches and tremors. In addition, there are no clinical records in more than four decades after separation from service supporting continuity of symptoms. Again, in making such a credibility finding, the Board is not finding that the Veteran has any intent to deceive., but instead may be simply mistaken in his recollections due to the fallibility of human memory. Nonetheless, the Board finds that further development is warranted. In the past, in-patient records may have been stored independently from, and not filed with, individual STRs, but instead filed by year and place of treatment. The RO should attempt to obtain all records, if any, for in-patient services beginning on August 22, 1959 while the Veteran was in Korea. In addition, the Veteran testified at the 2018 Board hearing that there may be recent outstanding and relevant David Grant Hosptial, Travis Air Force Base records. A remand is required to allow VA to request these records. The matters are REMANDED for the following action: 1. Obtain the Veteran’s federal records from David Grant Hospital, Travis Air Force Base. Document all requests for information as well as all responses in the claims file. 2. Obtain records of any inpatient treatment at the U.S. military facility in Korea where the Veteran was stationed in August 1959 (he was admitted on August 22, 1959 for approximately one week). (These records may be stored by the name of the hospital and date of hospitalization rather than the Veteran’s individual STRs.) Document all requests for information as well as all responses in the claims file. 3. Attempt to obtain the Veteran’s MMPA (Master Military Pay Account) for the period from November 1977 to November 1990 to determine his exact dates of service. 4. With regard to the Veteran’s claim for service connection for BILATERAL KNEE DISABILITY, obtain an opinion from an appropriate clinician regarding whether the Veteran’s bilateral knee disability is at least as likely as not related to service. The clinician should consider the pertinent evidence of record to include: a.) the Veteran’s assertion that his current knee disability is due to jumping off aircraft ramps and jumping on and off of trucks; b.) the Veteran’s 1962, 1977, 1981, and 1985 Reports of Medical History in which he denied knee complaints; c.) the Veteran separated from active service in 1962, and had reserve service of approximately two weeks a year ACDUTRA and weekend drills (INACDUTRA) between 1977 and 1990; d.) a January 1996 radiology report which reflects degenerative changes in the right knee; however, the left knee was unremarkable; e.) the Veteran’s age and body habitus (obese) when diagnosed; and f.) the January 2001 radiology report reflecting bilateral knee DJD. 5. With regard to the Veteran’s claim for service connection for a HEART DISABILITY, obtain a clinical opinion from an appropriate clinician as to whether it is as likely as not that the Veteran has atrial fibrillation causally related to active service or a period of ACDUTRA. The clinician should consider the pertinent evidence of record to include: a.) the Veteran’s exact dates of service (e.g. the Veteran separated from active duty in 1962, and thereafter, had periods of Reserve Inactive duty training (INACTDUTRA) and active duty for training (ACDUTRA) between November 1977 and November 1990. These periods of ACDUTRA averaged approximately two weeks a year; b.) an October 18, 1990 Medical Screening Summary – CardioVascular Risk Screening Program record which reflects “Abn” under “Electrocardiogram”; c.) whether a disability was actually incurred during a period of service or merely diagnosed at that time; and d.) whether the evidence supports a finding of chronic atrial fibrillation since a period of active service or ACDUTRA (i.e. is atrial fibrillation usually acute or chronic, and which does the evidence support in the Veteran’s situation?) 6. With regard to the Veteran’s claim for service connection for RESIDUALS OF ENCEPHALITIS, obtain a clinical opinion from an appropriate clinician as to whether it is as likely as not that the Veteran has residuals of encephalitis. The clinician should consider the pertinent evidence of record to include the following: a.) an August 22, 1959 STR which notes that the Veteran was admitted for hospitalization after he reported to the dispensary with a temperature of 103.4 and complaints of a headache. The notation reads “pos encephalitis”; b.) the Veteran’s contention of residuals of headaches, upper and lower extremity body tremors, chronic fatigue, whole body weakness, anemia, and mood disorders; c.) the Reports of Medical History which note that the Veteran reported his health was very good (February 1962), good (June 1977), excellent (June 1981), and very good (April 1985); and d.) an April 2000 Kaiser Permanente Adult Intake/Diagnostic Summary record which reflects that the Veteran denied current or past headaches and tremors. The clinician should discuss whether it is as likely as not that the Veteran would have residual symptoms with an onset several decades after separation from service. (The clinician should not consider that the Veteran had symptoms continuous since service unless there are   clinical records to support such a finding.) If an adequate opinion cannot be rendered without an examination, the Veteran should be scheduled for such. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Wishard