DVBCQPR3 ;;ALB-CIOFO/ECF - PTSD REVIEW QUESTIONNAIRE (continued); 9/20/2010
;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
;
TXT ;
;;
;; 6. Differentiation of symptoms
;;
;; Are you able to differentiate what portion of the symptom complex above
;; is caused by each diagnosis?
;; ___ Yes ___ No
;;
;; If yes, list which symptoms are attributable to each diagnosis, where
;; possible: __________________________________________________________________
;;
;; 7. Occupational and social impairment
;;
;; Which of the following best represents the Veteran's level of occupational
;; and social impairment?
;; (Check only one)
;;
;; ___ A mental condition has been formally diagnosed, but symptoms are not
;; severe enough either to interfere with occupational and social
;; functioning or to require continuous medication
;; ___ Occupational and social impairment due to mild or transient symptoms
;; which decrease work efficiency and ability to perform occupational tasks
;; only during periods of significant stress, or; symptoms controlled by
;; medication
;; ___ Occupational and social impairment with occasional decrease in work
;; efficiency and intermittent periods of inability to perform occupational
;; tasks, although generally functioning satisfactorily, with normal
;; routine behavior, self-care and conversation
;; ___ Occupational and social impairment with reduced reliability and
;; productivity
;; ___ Occupational and social impairment with deficiencies in most areas, such
;; as work, school, family relations, judgment, thinking and/or mood
;; ___ Total occupational and social impairment
;;^TOF^
;; 8. Current global assessment of functioning (GAF) score: __________
;;
;; 9. Competency
;;
;; Is the Veteran capable of managing his or her financial affairs?
;; ___ Yes ___ No
;;
;; If no, explain: ____________________________________________________________
;;
;; 10. Diagnostic testing
;;
;; Has any mental health testing been performed?
;; ___ Yes ___ No
;;
;; If yes, provide dates, types of testing and results: _______________________
;;
;; 11. Functional impact
;;
;; Does the Veteran's PTSD (and other mental disorders) impact his or her
;; ability to work?
;;
;; ___ Yes ___ No
;;
;; If yes, describe impact, providing one or more examples: ___________________
;;
;; ____________________________________________________________________________
;;
;; 12. Remarks, if any ________________________________________________________
;;
;; Psychiatrist/Psychologist/examiner signature & title: ______________________
;;
;; Psychiatrist/Psychologist/examiner printed name: ___________________________
;;
;; Date: ________________________ Phone: ____________________________________
;;
;; License #: _____________
;;
;; Psychiatrist/Psychologist/examiner address: ________________________________
;;
;; ____________________________________________________________________________
;;
;; NOTE: VA may request additional medical information, including additional
;; examinations if necessary to complete VA's review of the Veteran's
;; application.
;;
;;^END^
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQPR3 3297 printed Dec 13, 2024@01:47:51 Page 2
DVBCQPR3 ;;ALB-CIOFO/ECF - PTSD REVIEW QUESTIONNAIRE (continued); 9/20/2010
+1 ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
+2 ;
TXT ;
+1 ;;
+2 ;; 6. Differentiation of symptoms
+3 ;;
+4 ;; Are you able to differentiate what portion of the symptom complex above
+5 ;; is caused by each diagnosis?
+6 ;; ___ Yes ___ No
+7 ;;
+8 ;; If yes, list which symptoms are attributable to each diagnosis, where
+9 ;; possible: __________________________________________________________________
+10 ;;
+11 ;; 7. Occupational and social impairment
+12 ;;
+13 ;; Which of the following best represents the Veteran's level of occupational
+14 ;; and social impairment?
+15 ;; (Check only one)
+16 ;;
+17 ;; ___ A mental condition has been formally diagnosed, but symptoms are not
+18 ;; severe enough either to interfere with occupational and social
+19 ;; functioning or to require continuous medication
+20 ;; ___ Occupational and social impairment due to mild or transient symptoms
+21 ;; which decrease work efficiency and ability to perform occupational tasks
+22 ;; only during periods of significant stress, or; symptoms controlled by
+23 ;; medication
+24 ;; ___ Occupational and social impairment with occasional decrease in work
+25 ;; efficiency and intermittent periods of inability to perform occupational
+26 ;; tasks, although generally functioning satisfactorily, with normal
+27 ;; routine behavior, self-care and conversation
+28 ;; ___ Occupational and social impairment with reduced reliability and
+29 ;; productivity
+30 ;; ___ Occupational and social impairment with deficiencies in most areas, such
+31 ;; as work, school, family relations, judgment, thinking and/or mood
+32 ;; ___ Total occupational and social impairment
+33 ;;^TOF^
+34 ;; 8. Current global assessment of functioning (GAF) score: __________
+35 ;;
+36 ;; 9. Competency
+37 ;;
+38 ;; Is the Veteran capable of managing his or her financial affairs?
+39 ;; ___ Yes ___ No
+40 ;;
+41 ;; If no, explain: ____________________________________________________________
+42 ;;
+43 ;; 10. Diagnostic testing
+44 ;;
+45 ;; Has any mental health testing been performed?
+46 ;; ___ Yes ___ No
+47 ;;
+48 ;; If yes, provide dates, types of testing and results: _______________________
+49 ;;
+50 ;; 11. Functional impact
+51 ;;
+52 ;; Does the Veteran's PTSD (and other mental disorders) impact his or her
+53 ;; ability to work?
+54 ;;
+55 ;; ___ Yes ___ No
+56 ;;
+57 ;; If yes, describe impact, providing one or more examples: ___________________
+58 ;;
+59 ;; ____________________________________________________________________________
+60 ;;
+61 ;; 12. Remarks, if any ________________________________________________________
+62 ;;
+63 ;; Psychiatrist/Psychologist/examiner signature & title: ______________________
+64 ;;
+65 ;; Psychiatrist/Psychologist/examiner printed name: ___________________________
+66 ;;
+67 ;; Date: ________________________ Phone: ____________________________________
+68 ;;
+69 ;; License #: _____________
+70 ;;
+71 ;; Psychiatrist/Psychologist/examiner address: ________________________________
+72 ;;
+73 ;; ____________________________________________________________________________
+74 ;;
+75 ;; NOTE: VA may request additional medical information, including additional
+76 ;; examinations if necessary to complete VA's review of the Veteran's
+77 ;; application.
+78 ;;
+79 ;;^END^
+80 QUIT
