DVBCQPT2 ;;ALB-CIOFO/ECF - PTSD QUESTIONNAIRE ; 5/10/2010
;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
;
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.
;;
;; 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 VA Suicide Prevention
;; Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the
;; Veteran to emergency care.
;;
;; This form is for use only by VHA and VBA staff and contract psychiatrists
;; or psychologists.
;;
;; In order to conduct an initial examination for PTSD, the examiner must meet
;; one of the following criteria: 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; or 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.
;;
;; 1. Diagnosis
;;
;; a. Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV
;; criteria?
;;
;; ___ Yes ___ No
;;
;; Date of diagnosis of PTSD: ____________
;;
;; ICD code: _________
;;
;; Name of diagnosing facility or clinician: __________________________________
;;^TOF^
;; b. If no diagnosis of PTSD, check all that apply:
;;
;; ___ Veteran's symptoms do not meet the diagnostic criteria for PTSD under
;; DSM-IV criteria
;; ___ Veteran has another Axis I-IV diagnosis
;; If checked, list the Axis I-IV diagnoses and then also complete the
;; Mental Health and/or Eating Disorder Questionnaire(s):
;; ________________________________________________________________________
;;
;; ________________________________________________________________________
;; ___ Other trauma spectrum disorder
;; ___ Veteran does not have a mental disorder that conforms with DSM-IV
;; criteria
;; ___ Other (describe): ______________________________________________________
;;
;; c. If there is a diagnosis of PTSD, does the Veteran also have any other
;; Axis I-IV diagnoses?
;;
;; ___ Yes ___ No
;; (If yes, indicate additional diagnoses below. There is no need to also
;; complete the Mental Health or Eating Disorder Questionnaire)
;;
;; Additional mental health disorder diagnosis #1: _________________________
;; Date of diagnosis: ________________
;; ICD code: __________
;; Name of diagnosing facility or clinician: _______________________________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II ___ Axis III ___ Axis IV
;;
;; Describe the condition and its relationship to PTSD: ____________________
;;
;; _________________________________________________________________________
;;
;;
;; Additional mental health disorder diagnosis #2: __________________________
;; Date of diagnosis: ________________
;; ICD code: __________
;; Name of diagnosing facility or clinician: ________________________________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II ___ Axis III ___ Axis IV
;;
;; Describe the condition and its relationship to PTSD: _____________________
;;
;; __________________________________________________________________________
;;
;;^TOF^
;; Additional mental health disorder diagnosis #3: _________________________
;; Date of diagnosis: ________________
;; ICD code: __________
;; Name of diagnosing facility or clinician: _______________________________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II ___ Axis III ___ Axis IV
;;
;; Describe the condition and its relationship to PTSD: ____________________
;;
;; _________________________________________________________________________
;;
;; If additional diagnoses, describe, using above format: _____________________
;;
;; 2. Medical History
;;
;; Describe the history (including onset and course) of the Veteran's PTSD (and
;; other mental disorders) (brief summary):
;; ____________________________________________________________________________
;;
;; 3. Diagnostic criteria
;;
;; Please check boxes next to symptoms below. 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
;;
;; Criterion B: The traumatic event is persistently reexperienced 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 reexperienced
;;^TOF^
;; 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.
;; ___ No symptoms
;;^TOF^
;; Criterion F:
;;
;; ___ The symptoms described above in Criteria B, C and D cause clinically
;; significant distress or impairment in social, occupational, or other
;; important areas of functioning.
;; ___ The symptoms described above in Criteria B, C and D do NOT cause
;; clinically significant distress or impairment in social, occupational,
;; or other important areas of functioning.
;; ___ No symptoms
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQPT2 8661 printed Sep 23, 2025@19:23:58 Page 2
DVBCQPT2 ;;ALB-CIOFO/ECF - PTSD QUESTIONNAIRE ; 5/10/2010
+1 ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+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 VA Suicide Prevention
+10 ;; Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the
+11 ;; Veteran to emergency care.
+12 ;;
+13 ;; This form is for use only by VHA and VBA staff and contract psychiatrists
+14 ;; or psychologists.
+15 ;;
+16 ;; In order to conduct an initial examination for PTSD, the examiner must meet
+17 ;; one of the following criteria: a board-certified or board-eligible
+18 ;; psychiatrist; a licensed doctorate-level psychologist; a doctorate-level
+19 ;; mental health provider under the close supervision of a board-certified or
+20 ;; board-eligible psychiatrist or licensed doctorate-level psychologist; a
+21 ;; psychiatry resident under close supervision of a board-certified or
+22 ;; board-eligible psychiatrist or licensed doctorate-level psychologist; or a
+23 ;; clinical or counseling psychologist completing a one-year internship or
+24 ;; residency (for purposes of a doctorate-level degree) under close supervision
+25 ;; of a board-certified or board-eligible psychiatrist or licensed
+26 ;; doctorate-level psychologist.
+27 ;;
+28 ;; 1. Diagnosis
+29 ;;
+30 ;; a. Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV
+31 ;; criteria?
+32 ;;
+33 ;; ___ Yes ___ No
+34 ;;
+35 ;; Date of diagnosis of PTSD: ____________
+36 ;;
+37 ;; ICD code: _________
+38 ;;
+39 ;; Name of diagnosing facility or clinician: __________________________________
+40 ;;^TOF^
+41 ;; b. If no diagnosis of PTSD, check all that apply:
+42 ;;
+43 ;; ___ Veteran's symptoms do not meet the diagnostic criteria for PTSD under
+44 ;; DSM-IV criteria
+45 ;; ___ Veteran has another Axis I-IV diagnosis
+46 ;; If checked, list the Axis I-IV diagnoses and then also complete the
+47 ;; Mental Health and/or Eating Disorder Questionnaire(s):
+48 ;; ________________________________________________________________________
+49 ;;
+50 ;; ________________________________________________________________________
+51 ;; ___ Other trauma spectrum disorder
+52 ;; ___ Veteran does not have a mental disorder that conforms with DSM-IV
+53 ;; criteria
+54 ;; ___ Other (describe): ______________________________________________________
+55 ;;
+56 ;; c. If there is a diagnosis of PTSD, does the Veteran also have any other
+57 ;; Axis I-IV diagnoses?
+58 ;;
+59 ;; ___ Yes ___ No
+60 ;; (If yes, indicate additional diagnoses below. There is no need to also
+61 ;; complete the Mental Health or Eating Disorder Questionnaire)
+62 ;;
+63 ;; Additional mental health disorder diagnosis #1: _________________________
+64 ;; Date of diagnosis: ________________
+65 ;; ICD code: __________
+66 ;; Name of diagnosing facility or clinician: _______________________________
+67 ;; Indicate the Axis category:
+68 ;; ___ Axis I ___ Axis II ___ Axis III ___ Axis IV
+69 ;;
+70 ;; Describe the condition and its relationship to PTSD: ____________________
+71 ;;
+72 ;; _________________________________________________________________________
+73 ;;
+74 ;;
+75 ;; Additional mental health disorder diagnosis #2: __________________________
+76 ;; Date of diagnosis: ________________
+77 ;; ICD code: __________
+78 ;; Name of diagnosing facility or clinician: ________________________________
+79 ;; Indicate the Axis category:
+80 ;; ___ Axis I ___ Axis II ___ Axis III ___ Axis IV
+81 ;;
+82 ;; Describe the condition and its relationship to PTSD: _____________________
+83 ;;
+84 ;; __________________________________________________________________________
+85 ;;
+86 ;;^TOF^
+87 ;; Additional mental health disorder diagnosis #3: _________________________
+88 ;; Date of diagnosis: ________________
+89 ;; ICD code: __________
+90 ;; Name of diagnosing facility or clinician: _______________________________
+91 ;; Indicate the Axis category:
+92 ;; ___ Axis I ___ Axis II ___ Axis III ___ Axis IV
+93 ;;
+94 ;; Describe the condition and its relationship to PTSD: ____________________
+95 ;;
+96 ;; _________________________________________________________________________
+97 ;;
+98 ;; If additional diagnoses, describe, using above format: _____________________
+99 ;;
+100 ;; 2. Medical History
+101 ;;
+102 ;; Describe the history (including onset and course) of the Veteran's PTSD (and
+103 ;; other mental disorders) (brief summary):
+104 ;; ____________________________________________________________________________
+105 ;;
+106 ;; 3. Diagnostic criteria
+107 ;;
+108 ;; Please check boxes next to symptoms below. The diagnostic criteria for
+109 ;; PTSD, referred to as Criteria A-F, are from the Diagnostic and Statistical
+110 ;; Manual of Mental Disorders, 4th edition (DSM-IV).
+111 ;;
+112 ;; Criterion A: The Veteran has been exposed to a traumatic event where both
+113 ;; of the following were present:
+114 ;;
+115 ;; ___ The Veteran experienced, witnessed or was confronted with an event
+116 ;; that involved actual or threatened death or serious injury, or a
+117 ;; threat to the physical integrity of self or others.
+118 ;; ___ The Veteran's response involved intense fear, helplessness or horror.
+119 ;; ___ No exposure to a traumatic event
+120 ;;
+121 ;; Criterion B: The traumatic event is persistently reexperienced in 1 or more
+122 ;; of the following ways:
+123 ;;
+124 ;; ___ Recurrent and distressing recollections of the event, including
+125 ;; images, thoughts or perceptions
+126 ;; ___ Recurrent distressing dreams of the event
+127 ;; ___ Acting or feeling as if the traumatic event were recurring; this
+128 ;; includes a sense of reliving the experience, illusions, hallucinations
+129 ;; and dissociative flashback episodes, including those that occur on
+130 ;; awakening or when intoxicated
+131 ;; ___ Intense psychological distress at exposure to internal or external
+132 ;; cues that symbolize or resemble an aspect of the traumatic event
+133 ;; ___ Physiological reactivity on exposure to internal or external cues that
+134 ;; symbolize or resemble an aspect of the traumatic event
+135 ;; ___ The traumatic event is not persistently reexperienced
+136 ;;^TOF^
+137 ;; Criterion C: Persistent avoidance of stimuli associated with the trauma and
+138 ;; numbing of general responsiveness (not present before the trauma), as
+139 ;; indicated by 3 or more of the following:
+140 ;;
+141 ;; ___ Efforts to avoid thoughts, feelings or conversations associated with
+142 ;; the trauma
+143 ;; ___ Efforts to avoid activities, places or people that arouse
+144 ;; recollections of the trauma
+145 ;; ___ Inability to recall an important aspect of the trauma
+146 ;; ___ Markedly diminished interest or participation in significant
+147 ;; activities
+148 ;; ___ Feeling of detachment or estrangement from others
+149 ;; ___ Restricted range of affect (e.g., unable to have loving feelings)
+150 ;; ___ Sense of a foreshortened future (e.g., does not expect to have a
+151 ;; career, marriage, children or a normal life span)
+152 ;; ___ No persistent avoidance of stimuli associated with the trauma or
+153 ;; numbing of general responsiveness
+154 ;;
+155 ;; Criterion D: Persistent symptoms of increased arousal, not present before
+156 ;; the trauma, as indicated by 2 or more of the following:
+157 ;;
+158 ;; ___ Difficulty falling or staying asleep
+159 ;; ___ Irritability or outbursts of anger
+160 ;; ___ Difficulty concentrating
+161 ;; ___ Hypervigilance
+162 ;; ___ Exaggerated startle response
+163 ;; ___ No persistent symptoms of increased arousal
+164 ;;
+165 ;; Criterion E:
+166 ;;
+167 ;; ___ The duration of the symptoms described above in Criteria B, C and D
+168 ;; is more than 1 month.
+169 ;; ___ The duration of the symptoms described above in Criteria B, C and D
+170 ;; is less than 1 month.
+171 ;; ___ No symptoms
+172 ;;^TOF^
+173 ;; Criterion F:
+174 ;;
+175 ;; ___ The symptoms described above in Criteria B, C and D cause clinically
+176 ;; significant distress or impairment in social, occupational, or other
+177 ;; important areas of functioning.
+178 ;; ___ The symptoms described above in Criteria B, C and D do NOT cause
+179 ;; clinically significant distress or impairment in social, occupational,
+180 ;; or other important areas of functioning.
+181 ;; ___ No symptoms
+182 ;;
+183 QUIT
