DVBCQPR6 ;;ALB-CIOFO/ECF - PTSD REVIEW QUESTIONNAIRE (v2) ; 17/JUNE/2011
;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
;
TXT ;
;; 4. Symptoms
;;
;; For VA rating purposes, check all symptoms that apply to the Veteran's
;; diagnoses:
;;
;; ___ Depressed mood
;; ___ Anxiety
;; ___ Suspiciousness
;; ___ Panic attacks that occur weekly or less often
;; ___ Panic attacks more than once a week
;; ___ Near-continuous panic or depression affecting the ability to function
;; independently, appropriately and effectively
;; ___ Chronic sleep impairment
;; ___ Mild memory loss, such as forgetting names, directions or recent events
;; ___ Impairment of short- and long-term memory, for example, retention of
;; only highly learned material, while forgetting to complete tasks
;; ___ Memory loss for names of close relatives, own occupation, or own name
;; ___ Flattened affect
;; ___ Circumstantial, circumlocutory or stereotyped speech
;; ___ Speech intermittently illogical, obscure, or irrelevant
;; ___ Difficulty in understanding complex commands
;; ___ Impaired judgment
;; ___ Impaired abstract thinking
;; ___ Gross impairment in thought processes or communication
;; ___ Disturbances of motivation and mood
;; ___ Difficulty in establishing and maintaining effective work and social
;; relationships
;; ___ Difficulty in adapting to stressful circumstances, including work or
;; a worklike setting
;; ___ Inability to establish and maintain effective relationships
;; ___ Suicidal ideation
;; ___ Obsessional rituals which interfere with routine activities
;; ___ Impaired impulse control, such as unprovoked irritability with periods
;; of violence
;; ___ Spatial disorientation
;; ___ Persistent delusions or hallucinations
;; ___ Grossly inappropriate behavior
;; ___ Persistent danger of hurting self or others
;; ___ Neglect of personal appearance and hygiene
;; ___ Intermittent inability to perform activities of daily living, including
;; maintenance of minimal personal hygiene
;; ___ Disorientation to time or place
;;^TOF^
;; 5. Other symptoms
;;
;; Does the Veteran have any other symptoms attributable to PTSD (and other
;; mental disorders) that are not listed above?
;; ___ Yes ___ No
;; If yes, describe: __________________________________________________________
;;
;; 6. Competency
;;
;; Is the Veteran capable of managing his or her financial affairs?
;; ___ Yes ___ No
;; If no, explain: ____________________________________________________________
;;
;; 7. Remarks, if any: ________________________________________________________
;;
;; Psychiatrist/Psychologist signature & title: _______________________________
;;
;; Psychiatrist/Psychologist printed name: ____________________________________
;;
;; License #: ____________________ Date: ______________________________________
;;
;; Psychiatrist/Psychologist address: _________________________________________
;;
;; Phone: ________________________ Fax: _______________________________________
;;
;; 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[HDVBCQPR6 3321 printed Dec 13, 2024@01:47:54 Page 2
DVBCQPR6 ;;ALB-CIOFO/ECF - PTSD REVIEW QUESTIONNAIRE (v2) ; 17/JUNE/2011
+1 ;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; 4. Symptoms
+2 ;;
+3 ;; For VA rating purposes, check all symptoms that apply to the Veteran's
+4 ;; diagnoses:
+5 ;;
+6 ;; ___ Depressed mood
+7 ;; ___ Anxiety
+8 ;; ___ Suspiciousness
+9 ;; ___ Panic attacks that occur weekly or less often
+10 ;; ___ Panic attacks more than once a week
+11 ;; ___ Near-continuous panic or depression affecting the ability to function
+12 ;; independently, appropriately and effectively
+13 ;; ___ Chronic sleep impairment
+14 ;; ___ Mild memory loss, such as forgetting names, directions or recent events
+15 ;; ___ Impairment of short- and long-term memory, for example, retention of
+16 ;; only highly learned material, while forgetting to complete tasks
+17 ;; ___ Memory loss for names of close relatives, own occupation, or own name
+18 ;; ___ Flattened affect
+19 ;; ___ Circumstantial, circumlocutory or stereotyped speech
+20 ;; ___ Speech intermittently illogical, obscure, or irrelevant
+21 ;; ___ Difficulty in understanding complex commands
+22 ;; ___ Impaired judgment
+23 ;; ___ Impaired abstract thinking
+24 ;; ___ Gross impairment in thought processes or communication
+25 ;; ___ Disturbances of motivation and mood
+26 ;; ___ Difficulty in establishing and maintaining effective work and social
+27 ;; relationships
+28 ;; ___ Difficulty in adapting to stressful circumstances, including work or
+29 ;; a worklike setting
+30 ;; ___ Inability to establish and maintain effective relationships
+31 ;; ___ Suicidal ideation
+32 ;; ___ Obsessional rituals which interfere with routine activities
+33 ;; ___ Impaired impulse control, such as unprovoked irritability with periods
+34 ;; of violence
+35 ;; ___ Spatial disorientation
+36 ;; ___ Persistent delusions or hallucinations
+37 ;; ___ Grossly inappropriate behavior
+38 ;; ___ Persistent danger of hurting self or others
+39 ;; ___ Neglect of personal appearance and hygiene
+40 ;; ___ Intermittent inability to perform activities of daily living, including
+41 ;; maintenance of minimal personal hygiene
+42 ;; ___ Disorientation to time or place
+43 ;;^TOF^
+44 ;; 5. Other symptoms
+45 ;;
+46 ;; Does the Veteran have any other symptoms attributable to PTSD (and other
+47 ;; mental disorders) that are not listed above?
+48 ;; ___ Yes ___ No
+49 ;; If yes, describe: __________________________________________________________
+50 ;;
+51 ;; 6. Competency
+52 ;;
+53 ;; Is the Veteran capable of managing his or her financial affairs?
+54 ;; ___ Yes ___ No
+55 ;; If no, explain: ____________________________________________________________
+56 ;;
+57 ;; 7. Remarks, if any: ________________________________________________________
+58 ;;
+59 ;; Psychiatrist/Psychologist signature & title: _______________________________
+60 ;;
+61 ;; Psychiatrist/Psychologist printed name: ____________________________________
+62 ;;
+63 ;; License #: ____________________ Date: ______________________________________
+64 ;;
+65 ;; Psychiatrist/Psychologist address: _________________________________________
+66 ;;
+67 ;; Phone: ________________________ Fax: _______________________________________
+68 ;;
+69 ;; NOTE: VA may request additional medical information, including additional
+70 ;; examinations if necessary to complete VA's review of the Veteran's
+71 ;; application.
+72 ;;^END^
+73 QUIT
