- 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 Feb 18, 2025@23:14:16 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