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Routine: DVBCQPR3

DVBCQPR3.m

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  1. DVBCQPR3 ;;ALB-CIOFO/ECF - PTSD REVIEW QUESTIONNAIRE (continued); 9/20/2010
  1. ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
  1. ;
  1. TXT ;
  1. ;;
  1. ;; 6. Differentiation of symptoms
  1. ;;
  1. ;; Are you able to differentiate what portion of the symptom complex above
  1. ;; is caused by each diagnosis?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, list which symptoms are attributable to each diagnosis, where
  1. ;; possible: __________________________________________________________________
  1. ;;
  1. ;; 7. Occupational and social impairment
  1. ;;
  1. ;; Which of the following best represents the Veteran's level of occupational
  1. ;; and social impairment?
  1. ;; (Check only one)
  1. ;;
  1. ;; ___ A mental condition has been formally diagnosed, but symptoms are not
  1. ;; severe enough either to interfere with occupational and social
  1. ;; functioning or to require continuous medication
  1. ;; ___ Occupational and social impairment due to mild or transient symptoms
  1. ;; which decrease work efficiency and ability to perform occupational tasks
  1. ;; only during periods of significant stress, or; symptoms controlled by
  1. ;; medication
  1. ;; ___ Occupational and social impairment with occasional decrease in work
  1. ;; efficiency and intermittent periods of inability to perform occupational
  1. ;; tasks, although generally functioning satisfactorily, with normal
  1. ;; routine behavior, self-care and conversation
  1. ;; ___ Occupational and social impairment with reduced reliability and
  1. ;; productivity
  1. ;; ___ Occupational and social impairment with deficiencies in most areas, such
  1. ;; as work, school, family relations, judgment, thinking and/or mood
  1. ;; ___ Total occupational and social impairment
  1. ;;^TOF^
  1. ;; 8. Current global assessment of functioning (GAF) score: __________
  1. ;;
  1. ;; 9. Competency
  1. ;;
  1. ;; Is the Veteran capable of managing his or her financial affairs?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, explain: ____________________________________________________________
  1. ;;
  1. ;; 10. Diagnostic testing
  1. ;;
  1. ;; Has any mental health testing been performed?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, provide dates, types of testing and results: _______________________
  1. ;;
  1. ;; 11. Functional impact
  1. ;;
  1. ;; Does the Veteran's PTSD (and other mental disorders) impact his or her
  1. ;; ability to work?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, describe impact, providing one or more examples: ___________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; 12. Remarks, if any ________________________________________________________
  1. ;;
  1. ;; Psychiatrist/Psychologist/examiner signature & title: ______________________
  1. ;;
  1. ;; Psychiatrist/Psychologist/examiner printed name: ___________________________
  1. ;;
  1. ;; Date: ________________________ Phone: ____________________________________
  1. ;;
  1. ;; License #: _____________
  1. ;;
  1. ;; Psychiatrist/Psychologist/examiner address: ________________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; NOTE: VA may request additional medical information, including additional
  1. ;; examinations if necessary to complete VA's review of the Veteran's
  1. ;; application.
  1. ;;
  1. ;;^END^
  1. Q