DVBCQPR2 ;;ALB-CIOFO/ECF - PTSD REVIEW QUESTIONNAIRE ; 9/20/2010
;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
;
TXT ;
;;
;; Your patient is applying to the U. S. Department of Veterans Affairs
;; (VA) for disability benefits. VA will consider the information you
;; provide on this questionnaire as part of their evaluation in processing
;; the Veteran's claim.
;;
;; NOTE: If the Veteran experiences a mental health emergency during the
;; interview, please terminate the interview and obtain help, using local
;; resources as appropriate. You may also contact the VA Suicide Prevention
;; Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the
;; Veteran to emergency care.
;;
;; In order to conduct an initial or review examination for PTSD, the examiner
;; must meet one of the following criteria: a board-certified or board-eligible
;; psychiatrist; a licensed doctorate-level psychologist; a doctorate-level
;; mental health provider under the close supervision of a board-certified or
;; board-eligible psychiatrist or licensed doctorate-level psychologist; a
;; psychiatry resident under close supervision of a board-certified or board-
;; eligible psychiatrist or licensed doctorate-level psychologist; or a
;; clinical or counseling psychologist completing a one-year internship or
;; residency (for purposes of a doctorate-level degree) under close supervision
;; of a board-certified or board-eligible psychiatrist or licensed doctorate-
;; level psychologist.
;;
;; In order to conduct a REVIEW examination for PTSD, the examiner must meet
;; one of the criteria from above, OR be a licensed clinical social worker
;; (LCSW), a nurse practitioner, a clinical nurse specialist, or a physician
;; assistant, under close supervision of a board-certified or board-eligible
;; psychiatrist or licensed doctorate-level psychologist.
;;
;; 1. Diagnosis
;;
;; a. Does the Veteran have a diagnosis of PTSD that conforms with DSM-IV
;; criteria?
;; ___ Yes ___ No
;;
;; Date of diagnosis of PTSD: ___________ ICD code: _____________________
;;
;; Name of diagnosing facility or clinician: __________________________________
;;^TOF^
;; b. If no diagnosis of PTSD, check all that apply:
;;
;; ___ Veteran's symptoms do not meet the diagnostic criteria for PTSD under
;; DSM-IV criteria
;; ___ Veteran has another Axis I-IV diagnosis
;; If checked, list the Axis I-IV diagnoses and then also complete the
;; Mental Health and/or Eating Disorder Questionnaire(s):
;; _________________________________________________________________________
;; ___ Other trauma spectrum disorder
;; ___ Veteran does not have a mental disorder that conforms with DSM-IV
;; criteria
;; ___ Other (describe): ______________________________________________________
;;
;; c. If there is a diagnosis of PTSD, does the Veteran also have any other
;; Axis I-IV diagnoses?
;; ___ Yes ___ No
;; (If yes, indicate additional diagnoses below. There is no need to also
;; complete a Mental Health or Eating Disorder Questionnaire)
;;
;; Additional mental health disorder diagnosis #1: _________________________
;;
;; Date of diagnosis: ______________
;;
;; ICD code: _________
;;
;; Name of diagnosing facility or clinician: ________________________________
;;
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II ___ Axis III ___ Axis IV
;;
;; Describe the condition and its relationship to PTSD: _____________________
;;
;; __________________________________________________________________________
;;^TOF^
;; Additional mental health disorder diagnosis #2: __________________________
;;
;; Date of diagnosis: ________________
;;
;; ICD code: __________
;;
;; Name of diagnosing facility or clinician: ________________________________
;;
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II ___ Axis III ___ Axis IV
;;
;; Describe the condition and its relationship to PTSD: _____________________
;;
;; __________________________________________________________________________
;;
;; Additional mental health disorder diagnosis #3: __________________________
;;
;; Date of diagnosis:_________________
;;
;; ICD code: __________
;;
;; Name of diagnosing facility or clinician: ________________________________
;;
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II ___ Axis III ___ Axis IV
;;
;; Describe the condition and its relationship to PTSD: _____________________
;;
;; __________________________________________________________________________
;;
;;
;; If additional diagnoses, describe, using above format: ______________________
;;^TOF^
;; 2. Medical history
;;
;; Describe the history (including onset and course) of the Veteran's PTSD (and
;; other mental disorders) (brief summary):
;;_____________________________________________________________________________
;;
;; 3. Diagnostic criteria
;;
;; Please check boxes next to symptoms below. The diagnostic criteria for PTSD,
;; referred to as Criteria A-F, are from the Diagnostic and Statistical Manual
;; of Mental Disorders, 4th edition (DSM-IV).
;;
;; Criterion A: The Veteran has been exposed to a traumatic event where both of
;; the following were present:
;;
;; ___ The Veteran experienced, witnessed or was confronted with an event
;; that involved actual or threatened death or serious injury, or a
;; threat to the physical integrity of self or others.
;; ___ The Veteran's response involved intense fear, helplessness or horror.
;; ___ No exposure to a traumatic event
;;
;; Criterion B: The traumatic event is persistently reexperienced in 1 or more
;; of the following ways:
;;
;; ___ Recurrent and distressing recollections of the event, including images,
;; thoughts or perceptions
;; ___ Recurrent distressing dreams of the event
;; ___ Acting or feeling as if the traumatic event were recurring; this
;; includes a sense of reliving the experience, illusions, hallucinations
;; and dissociative flashback episodes, including those that occur on
;; awakening or when intoxicated
;; ___ Intense psychological distress at exposure to internal or external
;; cues that symbolize or resemble an aspect of the traumatic event
;; ___ Physiological reactivity on exposure to internal or external cues that
;; symbolize or resemble an aspect of the traumatic event
;; ___ The traumatic event is not persistently reexperienced
;;^TOF^
;; Criterion C: Persistent avoidance of stimuli associated with the trauma and
;; numbing of general responsiveness (not present before the trauma), as
;; indicated by 3 or more of the following:
;;
;; ___ Efforts to avoid thoughts, feelings or conversations associated with
;; the trauma
;; ___ Efforts to avoid activities, places or people that arouse
;; recollections of the trauma
;; ___ Inability to recall an important aspect of the trauma
;; ___ Markedly diminished interest or participation in significant
;; activities
;; ___ Feeling of detachment or estrangement from others
;; ___ Restricted range of affect (e.g., unable to have loving feelings)
;; ___ Sense of a foreshortened future (e.g., does not expect to have a
;; career, marriage, children or a normal life span)
;; ___ No persistent avoidance of stimuli associated with the trauma or
;; numbing of general responsiveness
;;
;; Criterion D: Persistent symptoms of increased arousal, not present before
;; the trauma, as indicated by 2 or more of the following:
;;
;; ___ Difficulty falling or staying asleep
;; ___ Irritability or outbursts of anger
;; ___ Difficulty concentrating
;; ___ Hypervigilance
;; ___ Exaggerated startle response
;; ___ No persistent symptoms of increased arousal
;;
;; Criterion E:
;;
;; ___ The duration of the symptoms described above in Criteria B, C and D
;; is more than 1 month.
;; ___ The duration of the symptoms described above in Criteria B, C and D
;; is less than 1 month.
;; ___ No symptoms
;;^TOF^
;; Criterion F:
;;
;; ___ The symptoms described above in Criteria B, C and D cause clinically
;; significant distress or impairment in social, occupational,
;; or other important areas of functioning.
;; ___ The symptoms described above in Criteria B, C and D do NOT cause
;; clinically significant distress or impairment in social, occupational,
;; or other important areas of functioning.
;; ___ No symptoms
;;
;; 4. Symptoms
;;
;; For each level below, check all symptoms that apply.
;;
;; Level I
;;
;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
;; If yes, check all that apply:
;;
;; ___ Depressed mood
;; ___ Anxiety
;; ___ Suspiciousness
;; ___ Panic attacks that occur weekly or less often
;; ___ Chronic sleep impairment
;; ___ Mild memory loss, such as forgetting names, directions or recent
;; events
;;
;; Level II
;;
;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
;; If yes, check all that apply:
;;
;; ___ Flattened affect
;; ___ Circumstantial, circumlocutory or stereotyped speech
;; ___ Panic attacks more than once a week
;; ___ Difficulty in understanding complex commands
;; ___ Impairment of short- and long-term memory, for example, retention of
;; only highly learned material, while forgetting to complete tasks
;; ___ Impaired judgment
;; ___ Impaired abstract thinking
;; ___ Disturbances of motivation and mood
;; ___ Difficulty in establishing and maintaining effective work and social
;; relationships
;;^TOF^
;; Level III
;;
;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
;; If yes, check all that apply:
;;
;; ___ Suicidal ideation
;; ___ Obsessional rituals which interfere with routine activities
;; ___ Speech intermittently illogical, obscure, or irrelevant
;; ___ Near-continuous panic or depression affecting the ability to function
;; independently, appropriately and effectively
;; ___ Impaired impulse control, such as unprovoked irritability with
;; periods of violence
;; ___ Spatial disorientation
;; ___ Neglect of personal appearance and hygiene
;; ___ Difficulty in adapting to stressful circumstances, including work or
;; a worklike setting
;; ___ Inability to establish and maintain effective relationships
;;
;; Level IV
;;
;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
;; If yes, check all that apply:
;;
;; ___ Gross impairment in thought processes or communication
;; ___ Persistent delusions or hallucinations
;; ___ Grossly inappropriate behavior
;; ___ Persistent danger of hurting self or others
;; ___ Intermittent inability to perform activities of daily living,
;; including maintenance of minimal personal hygiene
;; ___ Disorientation to time or place
;; ___ Memory loss for names of close relatives, own occupation, or own name
;;^TOF^
;; 5. Other symptoms
;;
;; Does the Veteran have any other symptoms attributable to PTSD (and other
;; mental disorders) that are not listed above?
;;
;; ___ Yes ___ No
;;
;; If yes, describe: __________________________________________________________
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQPR2 11869 printed Apr 09, 2024@20:52:29 Page 2
DVBCQPR2 ;;ALB-CIOFO/ECF - PTSD REVIEW QUESTIONNAIRE ; 9/20/2010
+1 ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;; NOTE: If the Veteran experiences a mental health emergency during the
+8 ;; interview, please terminate the interview and obtain help, using local
+9 ;; resources as appropriate. You may also contact the VA Suicide Prevention
+10 ;; Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the
+11 ;; Veteran to emergency care.
+12 ;;
+13 ;; In order to conduct an initial or review examination for PTSD, the examiner
+14 ;; must meet one of the following criteria: a board-certified or board-eligible
+15 ;; psychiatrist; a licensed doctorate-level psychologist; a doctorate-level
+16 ;; mental health provider under the close supervision of a board-certified or
+17 ;; board-eligible psychiatrist or licensed doctorate-level psychologist; a
+18 ;; psychiatry resident under close supervision of a board-certified or board-
+19 ;; eligible psychiatrist or licensed doctorate-level psychologist; or a
+20 ;; clinical or counseling psychologist completing a one-year internship or
+21 ;; residency (for purposes of a doctorate-level degree) under close supervision
+22 ;; of a board-certified or board-eligible psychiatrist or licensed doctorate-
+23 ;; level psychologist.
+24 ;;
+25 ;; In order to conduct a REVIEW examination for PTSD, the examiner must meet
+26 ;; one of the criteria from above, OR be a licensed clinical social worker
+27 ;; (LCSW), a nurse practitioner, a clinical nurse specialist, or a physician
+28 ;; assistant, under close supervision of a board-certified or board-eligible
+29 ;; psychiatrist or licensed doctorate-level psychologist.
+30 ;;
+31 ;; 1. Diagnosis
+32 ;;
+33 ;; a. Does the Veteran have a diagnosis of PTSD that conforms with DSM-IV
+34 ;; criteria?
+35 ;; ___ Yes ___ No
+36 ;;
+37 ;; Date of diagnosis of PTSD: ___________ ICD code: _____________________
+38 ;;
+39 ;; Name of diagnosing facility or clinician: __________________________________
+40 ;;^TOF^
+41 ;; b. If no diagnosis of PTSD, check all that apply:
+42 ;;
+43 ;; ___ Veteran's symptoms do not meet the diagnostic criteria for PTSD under
+44 ;; DSM-IV criteria
+45 ;; ___ Veteran has another Axis I-IV diagnosis
+46 ;; If checked, list the Axis I-IV diagnoses and then also complete the
+47 ;; Mental Health and/or Eating Disorder Questionnaire(s):
+48 ;; _________________________________________________________________________
+49 ;; ___ Other trauma spectrum disorder
+50 ;; ___ Veteran does not have a mental disorder that conforms with DSM-IV
+51 ;; criteria
+52 ;; ___ Other (describe): ______________________________________________________
+53 ;;
+54 ;; c. If there is a diagnosis of PTSD, does the Veteran also have any other
+55 ;; Axis I-IV diagnoses?
+56 ;; ___ Yes ___ No
+57 ;; (If yes, indicate additional diagnoses below. There is no need to also
+58 ;; complete a Mental Health or Eating Disorder Questionnaire)
+59 ;;
+60 ;; Additional mental health disorder diagnosis #1: _________________________
+61 ;;
+62 ;; Date of diagnosis: ______________
+63 ;;
+64 ;; ICD code: _________
+65 ;;
+66 ;; Name of diagnosing facility or clinician: ________________________________
+67 ;;
+68 ;; Indicate the Axis category:
+69 ;; ___ Axis I ___ Axis II ___ Axis III ___ Axis IV
+70 ;;
+71 ;; Describe the condition and its relationship to PTSD: _____________________
+72 ;;
+73 ;; __________________________________________________________________________
+74 ;;^TOF^
+75 ;; Additional mental health disorder diagnosis #2: __________________________
+76 ;;
+77 ;; Date of diagnosis: ________________
+78 ;;
+79 ;; ICD code: __________
+80 ;;
+81 ;; Name of diagnosing facility or clinician: ________________________________
+82 ;;
+83 ;; Indicate the Axis category:
+84 ;; ___ Axis I ___ Axis II ___ Axis III ___ Axis IV
+85 ;;
+86 ;; Describe the condition and its relationship to PTSD: _____________________
+87 ;;
+88 ;; __________________________________________________________________________
+89 ;;
+90 ;; Additional mental health disorder diagnosis #3: __________________________
+91 ;;
+92 ;; Date of diagnosis:_________________
+93 ;;
+94 ;; ICD code: __________
+95 ;;
+96 ;; Name of diagnosing facility or clinician: ________________________________
+97 ;;
+98 ;; Indicate the Axis category:
+99 ;; ___ Axis I ___ Axis II ___ Axis III ___ Axis IV
+100 ;;
+101 ;; Describe the condition and its relationship to PTSD: _____________________
+102 ;;
+103 ;; __________________________________________________________________________
+104 ;;
+105 ;;
+106 ;; If additional diagnoses, describe, using above format: ______________________
+107 ;;^TOF^
+108 ;; 2. Medical history
+109 ;;
+110 ;; Describe the history (including onset and course) of the Veteran's PTSD (and
+111 ;; other mental disorders) (brief summary):
+112 ;;_____________________________________________________________________________
+113 ;;
+114 ;; 3. Diagnostic criteria
+115 ;;
+116 ;; Please check boxes next to symptoms below. The diagnostic criteria for PTSD,
+117 ;; referred to as Criteria A-F, are from the Diagnostic and Statistical Manual
+118 ;; of Mental Disorders, 4th edition (DSM-IV).
+119 ;;
+120 ;; Criterion A: The Veteran has been exposed to a traumatic event where both of
+121 ;; the following were present:
+122 ;;
+123 ;; ___ The Veteran experienced, witnessed or was confronted with an event
+124 ;; that involved actual or threatened death or serious injury, or a
+125 ;; threat to the physical integrity of self or others.
+126 ;; ___ The Veteran's response involved intense fear, helplessness or horror.
+127 ;; ___ No exposure to a traumatic event
+128 ;;
+129 ;; Criterion B: The traumatic event is persistently reexperienced in 1 or more
+130 ;; of the following ways:
+131 ;;
+132 ;; ___ Recurrent and distressing recollections of the event, including images,
+133 ;; thoughts or perceptions
+134 ;; ___ Recurrent distressing dreams of the event
+135 ;; ___ Acting or feeling as if the traumatic event were recurring; this
+136 ;; includes a sense of reliving the experience, illusions, hallucinations
+137 ;; and dissociative flashback episodes, including those that occur on
+138 ;; awakening or when intoxicated
+139 ;; ___ Intense psychological distress at exposure to internal or external
+140 ;; cues that symbolize or resemble an aspect of the traumatic event
+141 ;; ___ Physiological reactivity on exposure to internal or external cues that
+142 ;; symbolize or resemble an aspect of the traumatic event
+143 ;; ___ The traumatic event is not persistently reexperienced
+144 ;;^TOF^
+145 ;; Criterion C: Persistent avoidance of stimuli associated with the trauma and
+146 ;; numbing of general responsiveness (not present before the trauma), as
+147 ;; indicated by 3 or more of the following:
+148 ;;
+149 ;; ___ Efforts to avoid thoughts, feelings or conversations associated with
+150 ;; the trauma
+151 ;; ___ Efforts to avoid activities, places or people that arouse
+152 ;; recollections of the trauma
+153 ;; ___ Inability to recall an important aspect of the trauma
+154 ;; ___ Markedly diminished interest or participation in significant
+155 ;; activities
+156 ;; ___ Feeling of detachment or estrangement from others
+157 ;; ___ Restricted range of affect (e.g., unable to have loving feelings)
+158 ;; ___ Sense of a foreshortened future (e.g., does not expect to have a
+159 ;; career, marriage, children or a normal life span)
+160 ;; ___ No persistent avoidance of stimuli associated with the trauma or
+161 ;; numbing of general responsiveness
+162 ;;
+163 ;; Criterion D: Persistent symptoms of increased arousal, not present before
+164 ;; the trauma, as indicated by 2 or more of the following:
+165 ;;
+166 ;; ___ Difficulty falling or staying asleep
+167 ;; ___ Irritability or outbursts of anger
+168 ;; ___ Difficulty concentrating
+169 ;; ___ Hypervigilance
+170 ;; ___ Exaggerated startle response
+171 ;; ___ No persistent symptoms of increased arousal
+172 ;;
+173 ;; Criterion E:
+174 ;;
+175 ;; ___ The duration of the symptoms described above in Criteria B, C and D
+176 ;; is more than 1 month.
+177 ;; ___ The duration of the symptoms described above in Criteria B, C and D
+178 ;; is less than 1 month.
+179 ;; ___ No symptoms
+180 ;;^TOF^
+181 ;; Criterion F:
+182 ;;
+183 ;; ___ The symptoms described above in Criteria B, C and D cause clinically
+184 ;; significant distress or impairment in social, occupational,
+185 ;; or other important areas of functioning.
+186 ;; ___ The symptoms described above in Criteria B, C and D do NOT cause
+187 ;; clinically significant distress or impairment in social, occupational,
+188 ;; or other important areas of functioning.
+189 ;; ___ No symptoms
+190 ;;
+191 ;; 4. Symptoms
+192 ;;
+193 ;; For each level below, check all symptoms that apply.
+194 ;;
+195 ;; Level I
+196 ;;
+197 ;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
+198 ;; If yes, check all that apply:
+199 ;;
+200 ;; ___ Depressed mood
+201 ;; ___ Anxiety
+202 ;; ___ Suspiciousness
+203 ;; ___ Panic attacks that occur weekly or less often
+204 ;; ___ Chronic sleep impairment
+205 ;; ___ Mild memory loss, such as forgetting names, directions or recent
+206 ;; events
+207 ;;
+208 ;; Level II
+209 ;;
+210 ;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
+211 ;; If yes, check all that apply:
+212 ;;
+213 ;; ___ Flattened affect
+214 ;; ___ Circumstantial, circumlocutory or stereotyped speech
+215 ;; ___ Panic attacks more than once a week
+216 ;; ___ Difficulty in understanding complex commands
+217 ;; ___ Impairment of short- and long-term memory, for example, retention of
+218 ;; only highly learned material, while forgetting to complete tasks
+219 ;; ___ Impaired judgment
+220 ;; ___ Impaired abstract thinking
+221 ;; ___ Disturbances of motivation and mood
+222 ;; ___ Difficulty in establishing and maintaining effective work and social
+223 ;; relationships
+224 ;;^TOF^
+225 ;; Level III
+226 ;;
+227 ;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
+228 ;; If yes, check all that apply:
+229 ;;
+230 ;; ___ Suicidal ideation
+231 ;; ___ Obsessional rituals which interfere with routine activities
+232 ;; ___ Speech intermittently illogical, obscure, or irrelevant
+233 ;; ___ Near-continuous panic or depression affecting the ability to function
+234 ;; independently, appropriately and effectively
+235 ;; ___ Impaired impulse control, such as unprovoked irritability with
+236 ;; periods of violence
+237 ;; ___ Spatial disorientation
+238 ;; ___ Neglect of personal appearance and hygiene
+239 ;; ___ Difficulty in adapting to stressful circumstances, including work or
+240 ;; a worklike setting
+241 ;; ___ Inability to establish and maintain effective relationships
+242 ;;
+243 ;; Level IV
+244 ;;
+245 ;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
+246 ;; If yes, check all that apply:
+247 ;;
+248 ;; ___ Gross impairment in thought processes or communication
+249 ;; ___ Persistent delusions or hallucinations
+250 ;; ___ Grossly inappropriate behavior
+251 ;; ___ Persistent danger of hurting self or others
+252 ;; ___ Intermittent inability to perform activities of daily living,
+253 ;; including maintenance of minimal personal hygiene
+254 ;; ___ Disorientation to time or place
+255 ;; ___ Memory loss for names of close relatives, own occupation, or own name
+256 ;;^TOF^
+257 ;; 5. Other symptoms
+258 ;;
+259 ;; Does the Veteran have any other symptoms attributable to PTSD (and other
+260 ;; mental disorders) that are not listed above?
+261 ;;
+262 ;; ___ Yes ___ No
+263 ;;
+264 ;; If yes, describe: __________________________________________________________
+265 ;;
+266 QUIT
