DVBCQPR5 ;;ALB-CIOFO/ECF - PTSD REVIEW QUESTIONNAIRE (v2) ; 17/JUNE/2011
;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
;
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.
;; Please note that this questionnaire is for disability evaluation, not for
;; treatment purposes.
;;
;; 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 Veterans Crisis Line at
;; 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the
;; Veteran to emergency care.
;;
;; The following health care providers can perform REVIEW examinations for
;; PTSD: 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; 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; or 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.
;;
;; SECTION I:
;; ----------
;;
;; 1. Diagnostic Summary
;;
;; This section should be completed based on the current examination and
;; clinical findings.
;;
;; a. Does the Veteran now have or has he/she ever been diagnosed with PTSD?
;; ___ Yes ___ No
;; If yes, continue to complete this Questionnaire.
;;
;; If no diagnosis of PTSD, and the Veteran has another Axis I and/or II
;; diagnosis, then continue to complete this Questionnaire and/or the Eating
;; Disorders Questionnaire: ___________________________________________________
;;
;; 2. Current Diagnoses
;;
;; a. Diagnosis #1: ______________________
;; ICD code: __________________________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II
;; Comments, if any: _______________________________________________________
;;^TOF^
;; Diagnosis #2: _________________________
;; ICD code: _____________________________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II
;; Comments, if any: __________________________________________________________
;;
;; Diagnosis #3: _________________________
;; ICD code: _____________________________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II
;; Comments, if any: __________________________________________________________
;;
;; Diagnosis #4: _________________________
;; ICD code: _____________________________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II
;; Comments, if any: __________________________________________________________
;;
;; If additional diagnoses, describe (using above format): ____________________
;;
;; b. Axis III - medical diagnoses (to include TBI): _________________________
;; ICD code: _____________________________
;; Comments, if any: __________________________________________________________
;;
;; c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
;; ____________________________________________________________________________
;;
;; d. Axis V - Current global assessment of functioning (GAF) score: __________
;; Comments, if any: __________________________________________________________
;;
;; 3. Differentiation of symptoms
;;
;; a. Does the Veteran have more than one mental disorder diagnosed?
;; ___ Yes ___ No
;; If yes, complete the following question:
;;
;; b. Is it possible to differentiate what symptom(s) is/are attributable to
;; each diagnosis?
;; ___ Yes ___ No ___ Not applicable (N/A)
;; If no, provide reason that it is not possible to differentiate what portion
;; of each symptom is attributable to each diagnosis: _________________________
;;
;; ____________________________________________________________________________
;;
;; If yes, list which symptoms are attributable to each diagnosis: ____________
;;
;; ____________________________________________________________________________
;;^TOF^
;; c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
;; ___ Yes ___ No ___ Not shown in records reviewed
;; Comments, if any: __________________________________________________________
;;
;; If yes, complete the following question:
;;
;; d. Is it possible to differentiate what symptom(s) indicated above is/are
;; attributable to each diagnosis?
;; ___ Yes ___ No ___ Not applicable (N/A)
;; If no, provide reason that it is not possible to differentiate what portion
;; of each symptom is attributable to each diagnosis: _________________________
;;
;; ____________________________________________________________________________
;;
;; If yes, list which symptoms are attributable to each diagnosis: ____________
;;
;; ____________________________________________________________________________
;;
;; 4. Occupational and social impairment
;;
;; a. Which of the following best summarizes the Veteran's level of occupational
;; and social impairment with regards to all mental diagnoses?
;; (Check only one)
;; ___ No mental disorder diagnosis
;; ___ 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
;;
;; b. For the indicated level of occupational and social impairment, is it
;; possible to differentiate what portion of the occupational and social
;; impairment indicated above is caused by each mental disorder?
;; ___ Yes ___ No ____ No other mental disorder has been diagnosed
;; If no, provide reason that it is not possible to differentiate what portion
;; of the indicated level of occupational and social impairment is attributable
;; to each diagnosis: _________________________________________________________
;; If yes, list which portion of the indicated level of occupational and social
;; impairment is attributable to each diagnosis: ______________________________
;;^TOF^
;; c. If a diagnosis of TBI exists, is it possible to differentiate what
;; portion of the occupational and social impairment indicated above is caused
;; by the TBI?
;; ___ Yes ___ No ___ No diagnosis of TBI
;; If no, provide reason that it is not possible to differentiate what portion
;; of the indicated level of occupational and social impairment is attributable
;; to each diagnosis: _________________________________________________________
;; If yes, list which portion of the indicated level of occupational and social
;; impairment is attributable to each diagnosis: ______________________________
;;
;; SECTION II:
;; -----------
;; Clinical Findings:
;; ------------------
;;
;; 1. Evidence review
;;
;; If any records (evidence) were reviewed, please list here: _________________
;;
;; 2. Recent History (since prior exam)
;;
;; a. Relevant Social/Marital/Family history: _________________________________
;;
;; b. Relevant Occupational and Educational history: __________________________
;;
;; c. Relevant Mental Health history, to include prescribed medications and
;; family mental health: ______________________________________________________
;;
;; d. Relevant Legal and Behavioral history: __________________________________
;;
;; e. Relevant Substance abuse history: _______________________________________
;;
;; f. Sentinel Event(s) (other than stressors): _______________________________
;;
;; g. Other, if any: __________________________________________________________
;;
;; 3. PTSD Diagnostic Criteria
;;
;; Please check criteria used for establishing the current PTSD diagnosis. 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.
;;^TOF^
;; Criterion B: The traumatic event is persistently re-experienced 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 re-experienced
;;
;; 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.
;; ___ Veteran does not meet full criteria for PTSD
;;^TOF^
;; Criterion F:
;; ___ The PTSD symptoms described above cause clinically significant distress
;; or impairment in social, occupational, or other important areas of
;; functioning.
;; ___ The PTSD symptoms described above do NOT cause clinically significant
;; distress or impairment in social, occupational, or other important areas
;; of functioning.
;; ___ Veteran does not meet full criteria for PTSD.
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQPR5 13219 printed Apr 09, 2024@20:49:47 Page 2
DVBCQPR5 ;;ALB-CIOFO/ECF - PTSD REVIEW QUESTIONNAIRE (v2) ; 17/JUNE/2011
+1 ;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;; Please note that this questionnaire is for disability evaluation, not for
+5 ;; treatment purposes.
+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 Veterans Crisis Line at
+10 ;; 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the
+11 ;; Veteran to emergency care.
+12 ;;
+13 ;; The following health care providers can perform REVIEW examinations for
+14 ;; PTSD: a board-certified or board-eligible psychiatrist; a licensed
+15 ;; doctorate-level psychologist; a doctorate-level mental health provider under
+16 ;; the close supervision of a board-certified or board-eligible psychiatrist or
+17 ;; licensed doctorate-level psychologist; a psychiatry resident under close
+18 ;; supervision of a board-certified or board-eligible psychiatrist or licensed
+19 ;; doctorate-level psychologist; a clinical or counseling psychologist
+20 ;; completing a one-year internship or residency (for purposes of a
+21 ;; doctorate-level degree) under close supervision of a board-certified or
+22 ;; board-eligible psychiatrist or licensed doctorate-level psychologist; or a
+23 ;; licensed clinical social worker (LCSW), a nurse practitioner, a clinical
+24 ;; nurse specialist, or a physician assistant, under close supervision of a
+25 ;; board-certified or board-eligible psychiatrist or licensed doctorate-level
+26 ;; psychologist.
+27 ;;
+28 ;; SECTION I:
+29 ;; ----------
+30 ;;
+31 ;; 1. Diagnostic Summary
+32 ;;
+33 ;; This section should be completed based on the current examination and
+34 ;; clinical findings.
+35 ;;
+36 ;; a. Does the Veteran now have or has he/she ever been diagnosed with PTSD?
+37 ;; ___ Yes ___ No
+38 ;; If yes, continue to complete this Questionnaire.
+39 ;;
+40 ;; If no diagnosis of PTSD, and the Veteran has another Axis I and/or II
+41 ;; diagnosis, then continue to complete this Questionnaire and/or the Eating
+42 ;; Disorders Questionnaire: ___________________________________________________
+43 ;;
+44 ;; 2. Current Diagnoses
+45 ;;
+46 ;; a. Diagnosis #1: ______________________
+47 ;; ICD code: __________________________
+48 ;; Indicate the Axis category:
+49 ;; ___ Axis I ___ Axis II
+50 ;; Comments, if any: _______________________________________________________
+51 ;;^TOF^
+52 ;; Diagnosis #2: _________________________
+53 ;; ICD code: _____________________________
+54 ;; Indicate the Axis category:
+55 ;; ___ Axis I ___ Axis II
+56 ;; Comments, if any: __________________________________________________________
+57 ;;
+58 ;; Diagnosis #3: _________________________
+59 ;; ICD code: _____________________________
+60 ;; Indicate the Axis category:
+61 ;; ___ Axis I ___ Axis II
+62 ;; Comments, if any: __________________________________________________________
+63 ;;
+64 ;; Diagnosis #4: _________________________
+65 ;; ICD code: _____________________________
+66 ;; Indicate the Axis category:
+67 ;; ___ Axis I ___ Axis II
+68 ;; Comments, if any: __________________________________________________________
+69 ;;
+70 ;; If additional diagnoses, describe (using above format): ____________________
+71 ;;
+72 ;; b. Axis III - medical diagnoses (to include TBI): _________________________
+73 ;; ICD code: _____________________________
+74 ;; Comments, if any: __________________________________________________________
+75 ;;
+76 ;; c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
+77 ;; ____________________________________________________________________________
+78 ;;
+79 ;; d. Axis V - Current global assessment of functioning (GAF) score: __________
+80 ;; Comments, if any: __________________________________________________________
+81 ;;
+82 ;; 3. Differentiation of symptoms
+83 ;;
+84 ;; a. Does the Veteran have more than one mental disorder diagnosed?
+85 ;; ___ Yes ___ No
+86 ;; If yes, complete the following question:
+87 ;;
+88 ;; b. Is it possible to differentiate what symptom(s) is/are attributable to
+89 ;; each diagnosis?
+90 ;; ___ Yes ___ No ___ Not applicable (N/A)
+91 ;; If no, provide reason that it is not possible to differentiate what portion
+92 ;; of each symptom is attributable to each diagnosis: _________________________
+93 ;;
+94 ;; ____________________________________________________________________________
+95 ;;
+96 ;; If yes, list which symptoms are attributable to each diagnosis: ____________
+97 ;;
+98 ;; ____________________________________________________________________________
+99 ;;^TOF^
+100 ;; c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
+101 ;; ___ Yes ___ No ___ Not shown in records reviewed
+102 ;; Comments, if any: __________________________________________________________
+103 ;;
+104 ;; If yes, complete the following question:
+105 ;;
+106 ;; d. Is it possible to differentiate what symptom(s) indicated above is/are
+107 ;; attributable to each diagnosis?
+108 ;; ___ Yes ___ No ___ Not applicable (N/A)
+109 ;; If no, provide reason that it is not possible to differentiate what portion
+110 ;; of each symptom is attributable to each diagnosis: _________________________
+111 ;;
+112 ;; ____________________________________________________________________________
+113 ;;
+114 ;; If yes, list which symptoms are attributable to each diagnosis: ____________
+115 ;;
+116 ;; ____________________________________________________________________________
+117 ;;
+118 ;; 4. Occupational and social impairment
+119 ;;
+120 ;; a. Which of the following best summarizes the Veteran's level of occupational
+121 ;; and social impairment with regards to all mental diagnoses?
+122 ;; (Check only one)
+123 ;; ___ No mental disorder diagnosis
+124 ;; ___ A mental condition has been formally diagnosed, but symptoms are not
+125 ;; severe enough either to interfere with occupational and social
+126 ;; functioning or to require continuous medication
+127 ;; ___ Occupational and social impairment due to mild or transient symptoms
+128 ;; which decrease work efficiency and ability to perform occupational tasks
+129 ;; only during periods of significant stress, or; symptoms controlled by
+130 ;; medication
+131 ;; ___ Occupational and social impairment with occasional decrease in work
+132 ;; efficiency and intermittent periods of inability to perform occupational
+133 ;; tasks, although generally functioning satisfactorily, with normal
+134 ;; routine behavior, self-care and conversation
+135 ;; ___ Occupational and social impairment with reduced reliability and
+136 ;; productivity
+137 ;; ___ Occupational and social impairment with deficiencies in most areas, such
+138 ;; as work, school, family relations, judgment, thinking and/or mood
+139 ;; ___ Total occupational and social impairment
+140 ;;
+141 ;; b. For the indicated level of occupational and social impairment, is it
+142 ;; possible to differentiate what portion of the occupational and social
+143 ;; impairment indicated above is caused by each mental disorder?
+144 ;; ___ Yes ___ No ____ No other mental disorder has been diagnosed
+145 ;; If no, provide reason that it is not possible to differentiate what portion
+146 ;; of the indicated level of occupational and social impairment is attributable
+147 ;; to each diagnosis: _________________________________________________________
+148 ;; If yes, list which portion of the indicated level of occupational and social
+149 ;; impairment is attributable to each diagnosis: ______________________________
+150 ;;^TOF^
+151 ;; c. If a diagnosis of TBI exists, is it possible to differentiate what
+152 ;; portion of the occupational and social impairment indicated above is caused
+153 ;; by the TBI?
+154 ;; ___ Yes ___ No ___ No diagnosis of TBI
+155 ;; If no, provide reason that it is not possible to differentiate what portion
+156 ;; of the indicated level of occupational and social impairment is attributable
+157 ;; to each diagnosis: _________________________________________________________
+158 ;; If yes, list which portion of the indicated level of occupational and social
+159 ;; impairment is attributable to each diagnosis: ______________________________
+160 ;;
+161 ;; SECTION II:
+162 ;; -----------
+163 ;; Clinical Findings:
+164 ;; ------------------
+165 ;;
+166 ;; 1. Evidence review
+167 ;;
+168 ;; If any records (evidence) were reviewed, please list here: _________________
+169 ;;
+170 ;; 2. Recent History (since prior exam)
+171 ;;
+172 ;; a. Relevant Social/Marital/Family history: _________________________________
+173 ;;
+174 ;; b. Relevant Occupational and Educational history: __________________________
+175 ;;
+176 ;; c. Relevant Mental Health history, to include prescribed medications and
+177 ;; family mental health: ______________________________________________________
+178 ;;
+179 ;; d. Relevant Legal and Behavioral history: __________________________________
+180 ;;
+181 ;; e. Relevant Substance abuse history: _______________________________________
+182 ;;
+183 ;; f. Sentinel Event(s) (other than stressors): _______________________________
+184 ;;
+185 ;; g. Other, if any: __________________________________________________________
+186 ;;
+187 ;; 3. PTSD Diagnostic Criteria
+188 ;;
+189 ;; Please check criteria used for establishing the current PTSD diagnosis. The
+190 ;; diagnostic criteria for PTSD, referred to as Criteria A-F, are from the
+191 ;; Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).
+192 ;;
+193 ;; Criterion A: The Veteran has been exposed to a traumatic event where both of
+194 ;; the following were present:
+195 ;; ___ The Veteran experienced, witnessed or was confronted with an event that
+196 ;; involved actual or threatened death or serious injury, or a threat to the
+197 ;; physical integrity of self or others.
+198 ;; ___ The Veteran's response involved intense fear, helplessness or horror.
+199 ;; ___ No exposure to a traumatic event.
+200 ;;^TOF^
+201 ;; Criterion B: The traumatic event is persistently re-experienced in 1 or more
+202 ;; of the following ways:
+203 ;; ___ Recurrent and distressing recollections of the event, including images,
+204 ;; thoughts or perceptions
+205 ;; ___ Recurrent distressing dreams of the event
+206 ;; ___ Acting or feeling as if the traumatic event were recurring; this
+207 ;; includes a sense of reliving the experience, illusions, hallucinations
+208 ;; and dissociative flashback episodes, including those that occur on
+209 ;; awakening or when intoxicated
+210 ;; ___ Intense psychological distress at exposure to internal or external cues
+211 ;; that symbolize or resemble an aspect of the traumatic event
+212 ;; ___ Physiological reactivity on exposure to internal or external cues that
+213 ;; symbolize or resemble an aspect of the traumatic event
+214 ;; ___ The traumatic event is not persistently re-experienced
+215 ;;
+216 ;; Criterion C: Persistent avoidance of stimuli associated with the trauma and
+217 ;; numbing of general responsiveness (not present before the trauma), as
+218 ;; indicated by 3 or more of the following:
+219 ;; ___ Efforts to avoid thoughts, feelings or conversations associated with the
+220 ;; trauma
+221 ;; ___ Efforts to avoid activities, places or people that arouse recollections
+222 ;; of the trauma
+223 ;; ___ Inability to recall an important aspect of the trauma
+224 ;; ___ Markedly diminished interest or participation in significant activities
+225 ;; ___ Feeling of detachment or estrangement from others
+226 ;; ___ Restricted range of affect (e.g., unable to have loving feelings)
+227 ;; ___ Sense of a foreshortened future (e.g., does not expect to have a career,
+228 ;; marriage, children or a normal life span)
+229 ;; ___ No persistent avoidance of stimuli associated with the trauma or numbing
+230 ;; of general responsiveness
+231 ;;
+232 ;; Criterion D: Persistent symptoms of increased arousal, not present before
+233 ;; the trauma, as indicated by 2 or more of the following:
+234 ;; ___ Difficulty falling or staying asleep
+235 ;; ___ Irritability or outbursts of anger
+236 ;; ___ Difficulty concentrating
+237 ;; ___ Hypervigilance
+238 ;; ___ Exaggerated startle response
+239 ;; ___ No persistent symptoms of increased arousal
+240 ;;
+241 ;; Criterion E:
+242 ;; ___ The duration of the symptoms described above in Criteria B, C and D is
+243 ;; more than 1 month.
+244 ;; ___ The duration of the symptoms described above in Criteria B, C and D is
+245 ;; less than 1 month.
+246 ;; ___ Veteran does not meet full criteria for PTSD
+247 ;;^TOF^
+248 ;; Criterion F:
+249 ;; ___ The PTSD symptoms described above cause clinically significant distress
+250 ;; or impairment in social, occupational, or other important areas of
+251 ;; functioning.
+252 ;; ___ The PTSD symptoms described above do NOT cause clinically significant
+253 ;; distress or impairment in social, occupational, or other important areas
+254 ;; of functioning.
+255 ;; ___ Veteran does not meet full criteria for PTSD.
+256 ;;
+257 QUIT
