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Routine: DVBCQPR6

DVBCQPR6.m

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  1. DVBCQPR6 ;;ALB-CIOFO/ECF - PTSD REVIEW QUESTIONNAIRE (v2) ; 17/JUNE/2011
  1.  ;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; 4. Symptoms
  1.  ;;
  1.  ;; For VA rating purposes, check all symptoms that apply to the Veteran's
  1.  ;; diagnoses:
  1.  ;;
  1.  ;; ___ Depressed mood
  1.  ;; ___ Anxiety
  1.  ;; ___ Suspiciousness
  1.  ;; ___ Panic attacks that occur weekly or less often
  1.  ;; ___ Panic attacks more than once a week
  1.  ;; ___ Near-continuous panic or depression affecting the ability to function
  1.  ;;     independently, appropriately and effectively
  1.  ;; ___ Chronic sleep impairment
  1.  ;; ___ Mild memory loss, such as forgetting names, directions or recent events
  1.  ;; ___ Impairment of short- and long-term memory, for example, retention of
  1.  ;;     only highly learned material, while forgetting to complete tasks
  1.  ;; ___ Memory loss for names of close relatives, own occupation, or own name
  1.  ;; ___ Flattened affect
  1.  ;; ___ Circumstantial, circumlocutory or stereotyped speech
  1.  ;; ___ Speech intermittently illogical, obscure, or irrelevant
  1.  ;; ___ Difficulty in understanding complex commands
  1.  ;; ___ Impaired judgment
  1.  ;; ___ Impaired abstract thinking
  1.  ;; ___ Gross impairment in thought processes or communication
  1.  ;; ___ Disturbances of motivation and mood
  1.  ;; ___ Difficulty in establishing and maintaining effective work and social
  1.  ;;     relationships
  1.  ;; ___ Difficulty in adapting to stressful circumstances, including work or
  1.  ;;     a worklike setting
  1.  ;; ___ Inability to establish and maintain effective relationships
  1.  ;; ___ Suicidal ideation
  1.  ;; ___ Obsessional rituals which interfere with routine activities
  1.  ;; ___ Impaired impulse control, such as unprovoked irritability with periods
  1.  ;;     of violence
  1.  ;; ___ Spatial disorientation
  1.  ;; ___ Persistent delusions or hallucinations
  1.  ;; ___ Grossly inappropriate behavior
  1.  ;; ___ Persistent danger of hurting self or others
  1.  ;; ___ Neglect of personal appearance and hygiene
  1.  ;; ___ Intermittent inability to perform activities of daily living, including
  1.  ;;     maintenance of minimal personal hygiene
  1.  ;; ___ Disorientation to time or place
  1.  ;;^TOF^
  1.  ;; 5. Other symptoms
  1.  ;;
  1.  ;; Does the Veteran have any other symptoms attributable to PTSD (and other
  1.  ;; mental disorders) that are not listed above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe: __________________________________________________________
  1.  ;;
  1.  ;; 6. Competency
  1.  ;;
  1.  ;; Is the Veteran capable of managing his or her financial affairs?
  1.  ;; ___ Yes   ___ No
  1.  ;; If no, explain: ____________________________________________________________
  1.  ;;
  1.  ;; 7. Remarks, if any: ________________________________________________________
  1.  ;;
  1.  ;; Psychiatrist/Psychologist signature & title: _______________________________
  1.  ;;
  1.  ;; Psychiatrist/Psychologist printed name: ____________________________________
  1.  ;;
  1.  ;; License #: ____________________ Date: ______________________________________
  1.  ;;
  1.  ;; Psychiatrist/Psychologist address: _________________________________________
  1.  ;;
  1.  ;; Phone: ________________________ Fax: _______________________________________
  1.  ;;
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's
  1.  ;; application.
  1.  ;;^END^
  1.  Q