DVBCQPR6.m

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 ---DVBCQPR6   3321     printed  Apr 09, 2024@20:51:57                                                                                                                                                                                                    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