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Routine: DVBCQPR5

DVBCQPR5.m

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  1. DVBCQPR5 ;;ALB-CIOFO/ECF - PTSD REVIEW QUESTIONNAIRE (v2) ; 17/JUNE/2011
  1.  ;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1.  ;; disability benefits.  VA will consider the information you provide on this
  1.  ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1.  ;; Please note that this questionnaire is for disability evaluation, not for
  1.  ;; treatment purposes.
  1.  ;;
  1.  ;; NOTE: If the Veteran experiences a mental health emergency during the
  1.  ;; interview, please terminate the interview and obtain help, using local
  1.  ;; resources as appropriate. You may also contact the Veterans Crisis Line at
  1.  ;; 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the
  1.  ;; Veteran to emergency care.
  1.  ;;
  1.  ;; The following health care providers can perform REVIEW examinations for
  1.  ;; PTSD: a board-certified or board-eligible psychiatrist; a licensed
  1.  ;; doctorate-level psychologist; a doctorate-level mental health provider under
  1.  ;; the close supervision of a board-certified or board-eligible psychiatrist or
  1.  ;; licensed doctorate-level psychologist; a psychiatry resident under close
  1.  ;; supervision of a board-certified or board-eligible psychiatrist or licensed
  1.  ;; doctorate-level psychologist; a clinical or counseling psychologist
  1.  ;; completing a one-year internship or residency (for purposes of a
  1.  ;; doctorate-level degree) under close supervision of a board-certified or
  1.  ;; board-eligible psychiatrist or licensed doctorate-level psychologist; or a
  1.  ;; licensed clinical social worker (LCSW), a nurse practitioner, a clinical
  1.  ;; nurse specialist, or a physician assistant, under close supervision of a
  1.  ;; board-certified or board-eligible psychiatrist or licensed doctorate-level
  1.  ;; psychologist.
  1.  ;;
  1.  ;;                                    SECTION I:
  1.  ;;                                    ----------
  1.  ;;
  1.  ;; 1. Diagnostic Summary
  1.  ;;
  1.  ;; This section should be completed based on the current examination and
  1.  ;; clinical findings.
  1.  ;;
  1.  ;; a. Does the Veteran now have or has he/she ever been diagnosed with PTSD?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, continue to complete this Questionnaire.
  1.  ;;
  1.  ;; If no diagnosis of PTSD, and the Veteran has another Axis I and/or II
  1.  ;; diagnosis, then continue to complete this Questionnaire and/or the Eating
  1.  ;; Disorders Questionnaire: ___________________________________________________
  1.  ;; 
  1.  ;; 2. Current Diagnoses
  1.  ;;
  1.  ;; a. Diagnosis #1: ______________________
  1.  ;;    ICD code: __________________________
  1.  ;;    Indicate the Axis category:
  1.  ;;    ___ Axis I   ___ Axis II
  1.  ;;    Comments, if any: _______________________________________________________
  1.  ;;^TOF^
  1.  ;; Diagnosis #2: _________________________
  1.  ;; ICD code: _____________________________
  1.  ;; Indicate the Axis category:
  1.  ;;     ___ Axis I   ___ Axis II
  1.  ;; Comments, if any: __________________________________________________________
  1.  ;; 
  1.  ;; Diagnosis #3: _________________________
  1.  ;; ICD code: _____________________________
  1.  ;; Indicate the Axis category:
  1.  ;;     ___ Axis I   ___ Axis II
  1.  ;; Comments, if any: __________________________________________________________
  1.  ;;
  1.  ;; Diagnosis #4: _________________________
  1.  ;; ICD code: _____________________________
  1.  ;; Indicate the Axis category:
  1.  ;;     ___ Axis I   ___ Axis II
  1.  ;; Comments, if any: __________________________________________________________
  1.  ;;
  1.  ;; If additional diagnoses, describe (using above format): ____________________
  1.  ;;
  1.  ;; b. Axis III - medical diagnoses (to include TBI):  _________________________
  1.  ;; ICD code: _____________________________
  1.  ;; Comments, if any: __________________________________________________________
  1.  ;;
  1.  ;; c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; d. Axis V - Current global assessment of functioning (GAF) score: __________
  1.  ;; Comments, if any: __________________________________________________________
  1.  ;;
  1.  ;; 3.  Differentiation of symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have more than one mental disorder diagnosed?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete the following question:
  1.  ;;
  1.  ;; b. Is it possible to differentiate what symptom(s) is/are attributable to
  1.  ;; each diagnosis?
  1.  ;; ___ Yes   ___ No  ___ Not applicable (N/A)
  1.  ;; If no, provide reason that it is not possible to differentiate what portion
  1.  ;; of each symptom is attributable to each diagnosis: _________________________
  1.  ;;
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; If yes, list which symptoms are attributable to each diagnosis: ____________
  1.  ;;
  1.  ;; ____________________________________________________________________________
  1.  ;;^TOF^
  1.  ;; c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
  1.  ;; ___ Yes   ___ No   ___ Not shown in records reviewed
  1.  ;; Comments, if any: __________________________________________________________
  1.  ;;
  1.  ;; If yes, complete the following question:
  1.  ;;
  1.  ;; d. Is it possible to differentiate what symptom(s) indicated above is/are
  1.  ;; attributable to each diagnosis?
  1.  ;; ___ Yes   ___ No   ___ Not applicable (N/A)
  1.  ;; If no, provide reason that it is not possible to differentiate what portion
  1.  ;; of each symptom is attributable to each diagnosis: _________________________
  1.  ;;
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; If yes, list which symptoms are attributable to each diagnosis: ____________
  1.  ;;
  1.  ;; ____________________________________________________________________________
  1.  ;; 
  1.  ;; 4. Occupational and social impairment
  1.  ;;
  1.  ;; a. Which of the following best summarizes the Veteran's level of occupational
  1.  ;; and social impairment with regards to all mental diagnoses?
  1.  ;; (Check only one)
  1.  ;; ___ No mental disorder diagnosis
  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.  ;;
  1.  ;; b. For the indicated level of occupational and social impairment, is it
  1.  ;; possible to differentiate what portion of the occupational and social
  1.  ;; impairment indicated above is caused by each mental disorder?
  1.  ;; ___ Yes   ___ No   ____ No other mental disorder has been diagnosed
  1.  ;; If no, provide reason that it is not possible to differentiate what portion
  1.  ;; of the indicated level of occupational and social impairment is attributable
  1.  ;; to each diagnosis: _________________________________________________________
  1.  ;; If yes, list which portion of the indicated level of occupational and social
  1.  ;; impairment is attributable to each diagnosis: ______________________________
  1.  ;;^TOF^
  1.  ;; c. If a diagnosis of TBI exists, is it possible to differentiate what
  1.  ;; portion of the occupational and social impairment indicated above is caused
  1.  ;; by the TBI?
  1.  ;; ___ Yes   ___ No   ___ No diagnosis of TBI
  1.  ;; If no, provide reason that it is not possible to differentiate what portion
  1.  ;; of the indicated level of occupational and social impairment is attributable
  1.  ;; to each diagnosis: _________________________________________________________
  1.  ;; If yes, list which portion of the indicated level of occupational and social
  1.  ;; impairment is attributable to each diagnosis: ______________________________
  1.  ;;
  1.  ;;                                 SECTION II:
  1.  ;;                                 -----------
  1.  ;;                              Clinical Findings:
  1.  ;;                              ------------------
  1.  ;;
  1.  ;; 1. Evidence review
  1.  ;;
  1.  ;; If any records (evidence) were reviewed, please list here: _________________
  1.  ;;
  1.  ;; 2. Recent History (since prior exam)
  1.  ;;
  1.  ;; a. Relevant Social/Marital/Family history: _________________________________
  1.  ;;
  1.  ;; b. Relevant Occupational and Educational history: __________________________
  1.  ;;
  1.  ;; c. Relevant Mental Health history, to include prescribed medications and
  1.  ;; family mental health: ______________________________________________________
  1.  ;;
  1.  ;; d. Relevant Legal and Behavioral history: __________________________________
  1.  ;;
  1.  ;; e. Relevant Substance abuse history: _______________________________________
  1.  ;;
  1.  ;; f. Sentinel Event(s) (other than stressors): _______________________________
  1.  ;;
  1.  ;; g. Other, if any: __________________________________________________________
  1.  ;;
  1.  ;; 3. PTSD Diagnostic Criteria
  1.  ;;
  1.  ;; Please check criteria used for establishing the current PTSD diagnosis. The
  1.  ;; diagnostic criteria for PTSD, referred to as Criteria A-F, are from the
  1.  ;; Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).
  1.  ;;
  1.  ;; Criterion A: The Veteran has been exposed to a traumatic event where both of
  1.  ;; the following were present:
  1.  ;; ___ The Veteran experienced, witnessed or was confronted with an event that
  1.  ;;     involved actual or threatened death or serious injury, or a threat to the
  1.  ;;     physical integrity of self or others.
  1.  ;; ___ The Veteran's response involved intense fear, helplessness or horror.
  1.  ;; ___ No exposure to a traumatic event.
  1.  ;;^TOF^
  1.  ;; Criterion B: The traumatic event is persistently re-experienced in 1 or more
  1.  ;; of the following ways:
  1.  ;; ___ Recurrent and distressing recollections of the event, including images,
  1.  ;;     thoughts or perceptions
  1.  ;; ___ Recurrent distressing dreams of the event
  1.  ;; ___ Acting or feeling as if the traumatic event were recurring; this
  1.  ;;     includes a sense of reliving the experience, illusions, hallucinations
  1.  ;;     and dissociative flashback episodes, including those that occur on
  1.  ;;     awakening or when intoxicated
  1.  ;; ___ Intense psychological distress at exposure to internal or external cues
  1.  ;;     that symbolize or resemble an aspect of the traumatic event
  1.  ;; ___ Physiological reactivity on exposure to internal or external cues that
  1.  ;;     symbolize or resemble an aspect of the traumatic event
  1.  ;; ___ The traumatic event is not persistently re-experienced
  1.  ;;
  1.  ;; Criterion C: Persistent avoidance of stimuli associated with the trauma and
  1.  ;; numbing of general responsiveness (not present before the trauma), as
  1.  ;; indicated by 3 or more of the following:
  1.  ;; ___ Efforts to avoid thoughts, feelings or conversations associated with the
  1.  ;;     trauma
  1.  ;; ___ Efforts to avoid activities, places or people that arouse recollections
  1.  ;;     of the trauma
  1.  ;; ___ Inability to recall an important aspect of the trauma
  1.  ;; ___ Markedly diminished interest or participation in significant activities
  1.  ;; ___ Feeling of detachment or estrangement from others
  1.  ;; ___ Restricted range of affect (e.g., unable to have loving feelings)
  1.  ;; ___ Sense of a foreshortened future (e.g., does not expect to have a career,
  1.  ;;     marriage, children or a normal life span)
  1.  ;; ___ No persistent avoidance of stimuli associated with the trauma or numbing
  1.  ;;     of general responsiveness
  1.  ;;
  1.  ;; Criterion D: Persistent symptoms of increased arousal, not present before
  1.  ;; the trauma, as indicated by 2 or more of the following:
  1.  ;; ___ Difficulty falling or staying asleep
  1.  ;; ___ Irritability or outbursts of anger
  1.  ;; ___ Difficulty concentrating
  1.  ;; ___ Hypervigilance
  1.  ;; ___ Exaggerated startle response
  1.  ;; ___ No persistent symptoms of increased arousal
  1.  ;;
  1.  ;; Criterion E:
  1.  ;; ___ The duration of the symptoms described above in Criteria B, C and D is
  1.  ;;     more than 1 month.
  1.  ;; ___ The duration of the symptoms described above in Criteria B, C and D is
  1.  ;;     less than 1 month.
  1.  ;; ___ Veteran does not meet full criteria for PTSD
  1.  ;;^TOF^
  1.  ;; Criterion F:
  1.  ;; ___ The PTSD symptoms described above cause clinically significant distress
  1.  ;;     or impairment in social, occupational, or other important areas of
  1.  ;;     functioning.
  1.  ;; ___ The PTSD symptoms described above do NOT cause clinically significant
  1.  ;;     distress or impairment in social, occupational, or other important areas
  1.  ;;     of functioning.
  1.  ;; ___ Veteran does not meet full criteria for PTSD.
  1.  ;;
  1.  Q