Home   Package List   Routine Alphabetical List   Global Alphabetical List   FileMan Files List   FileMan Sub-Files List   Package Component Lists   Package-Namespace Mapping  
Routine: DVBCQPT2

DVBCQPT2.m

Go to the documentation of this file. 
  1. DVBCQPT2  ;;ALB-CIOFO/ECF - PTSD QUESTIONNAIRE ; 5/10/2010
  1.  ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs
  1.  ;; (VA) for disability benefits.  VA will consider the information you
  1.  ;; provide on this questionnaire as part of their evaluation in processing
  1.  ;; the Veteran's claim.
  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 VA Suicide Prevention
  1.  ;; Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the
  1.  ;; Veteran to emergency care.
  1.  ;;
  1.  ;; This form is for use only by VHA and VBA staff and contract psychiatrists
  1.  ;; or psychologists.
  1.  ;;
  1.  ;; In order to conduct an initial examination for PTSD, the examiner must meet
  1.  ;; one of the following criteria: a board-certified or board-eligible
  1.  ;; psychiatrist; a licensed doctorate-level psychologist; a doctorate-level
  1.  ;; mental health provider under the close supervision of a board-certified or
  1.  ;; board-eligible psychiatrist or licensed doctorate-level psychologist; a
  1.  ;; psychiatry resident under close supervision of a board-certified or
  1.  ;; board-eligible psychiatrist or licensed doctorate-level psychologist; or a
  1.  ;; clinical or counseling psychologist completing a one-year internship or
  1.  ;; residency (for purposes of a doctorate-level degree) under close supervision
  1.  ;; of a board-certified or board-eligible psychiatrist or licensed
  1.  ;; doctorate-level psychologist. 
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;;
  1.  ;; a. Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV 
  1.  ;; criteria?
  1.  ;;
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; Date of diagnosis of PTSD: ____________
  1.  ;;
  1.  ;; ICD code: _________
  1.  ;;
  1.  ;; Name of diagnosing facility or clinician: __________________________________
  1.  ;;^TOF^
  1.  ;; b. If no diagnosis of PTSD, check all that apply:
  1.  ;;
  1.  ;; ___ Veteran's symptoms do not meet the diagnostic criteria for PTSD under
  1.  ;;     DSM-IV criteria
  1.  ;; ___ Veteran has another Axis I-IV diagnosis
  1.  ;;     If checked, list the Axis I-IV diagnoses and then also complete the
  1.  ;;     Mental Health and/or Eating Disorder Questionnaire(s):
  1.  ;;     ________________________________________________________________________
  1.  ;;
  1.  ;;     ________________________________________________________________________
  1.  ;; ___ Other trauma spectrum disorder
  1.  ;; ___ Veteran does not have a mental disorder that conforms with DSM-IV
  1.  ;;     criteria
  1.  ;; ___ Other (describe): ______________________________________________________
  1.  ;; 
  1.  ;; c. If there is a diagnosis of PTSD, does the Veteran also have any other
  1.  ;;    Axis I-IV diagnoses?
  1.  ;;
  1.  ;; ___ Yes   ___ No
  1.  ;; (If yes, indicate additional diagnoses below. There is no need to also
  1.  ;; complete the Mental Health or Eating Disorder Questionnaire)
  1.  ;;
  1.  ;;    Additional mental health disorder diagnosis #1: _________________________
  1.  ;;    Date of diagnosis: ________________
  1.  ;;    ICD code: __________
  1.  ;;    Name of diagnosing facility or clinician: _______________________________
  1.  ;;    Indicate the Axis category:
  1.  ;;    ___ Axis I    ___ Axis II    ___ Axis III    ___ Axis IV
  1.  ;; 
  1.  ;;    Describe the condition and its relationship to PTSD: ____________________
  1.  ;;
  1.  ;;    _________________________________________________________________________
  1.  ;;
  1.  ;;
  1.  ;;   Additional mental health disorder diagnosis #2: __________________________
  1.  ;;   Date of diagnosis: ________________
  1.  ;;   ICD code: __________
  1.  ;;   Name of diagnosing facility or clinician: ________________________________
  1.  ;;   Indicate the Axis category:
  1.  ;;   ___ Axis I    ___ Axis II    ___ Axis III    ___ Axis IV
  1.  ;;
  1.  ;;   Describe the condition and its relationship to PTSD: _____________________
  1.  ;;
  1.  ;;   __________________________________________________________________________
  1.  ;;
  1.  ;;^TOF^
  1.  ;;    Additional mental health disorder diagnosis #3: _________________________
  1.  ;;    Date of diagnosis: ________________
  1.  ;;    ICD code: __________
  1.  ;;    Name of diagnosing facility or clinician: _______________________________
  1.  ;;    Indicate the Axis category:
  1.  ;;    ___ Axis I    ___ Axis II    ___ Axis III    ___ Axis IV
  1.  ;; 
  1.  ;;    Describe the condition and its relationship to PTSD: ____________________
  1.  ;;
  1.  ;;    _________________________________________________________________________
  1.  ;;
  1.  ;; If additional diagnoses, describe, using above format: _____________________
  1.  ;;
  1.  ;; 2. Medical History
  1.  ;;
  1.  ;; Describe the history (including onset and course) of the Veteran's PTSD (and
  1.  ;; other mental disorders) (brief summary): 
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 3. Diagnostic criteria
  1.  ;;
  1.  ;; Please check boxes next to symptoms below. The diagnostic criteria for
  1.  ;; PTSD, referred to as Criteria A-F, are from the Diagnostic and Statistical
  1.  ;; Manual of Mental Disorders, 4th edition (DSM-IV).
  1.  ;;
  1.  ;; Criterion A: The Veteran has been exposed to a traumatic event where both
  1.  ;; of the following were present:
  1.  ;;
  1.  ;;   ___ The Veteran experienced, witnessed or was confronted with an event
  1.  ;;       that involved actual or threatened death or serious injury, or a
  1.  ;;       threat to the 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.  ;;
  1.  ;; Criterion B: The traumatic event is persistently reexperienced in 1 or more
  1.  ;; of the following ways:
  1.  ;;
  1.  ;;   ___ Recurrent and distressing recollections of the event, including
  1.  ;;       images, 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
  1.  ;;       cues 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 reexperienced
  1.  ;;^TOF^
  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.  ;;
  1.  ;;   ___ Efforts to avoid thoughts, feelings or conversations associated with
  1.  ;;       the trauma
  1.  ;;   ___ Efforts to avoid activities, places or people that arouse
  1.  ;;       recollections of the trauma
  1.  ;;   ___ Inability to recall an important aspect of the trauma
  1.  ;;   ___ Markedly diminished interest or participation in significant          
  1.  ;;       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
  1.  ;;       career, marriage, children or a normal life span)
  1.  ;;   ___ No persistent avoidance of stimuli associated with the trauma or
  1.  ;;       numbing 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.  ;;
  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.  ;;
  1.  ;;   ___ The duration of the symptoms described above in Criteria B, C and D
  1.  ;;       is more than 1 month.
  1.  ;;   ___ The duration of the symptoms described above in Criteria B, C and D
  1.  ;;       is less than 1 month.
  1.  ;;   ___ No symptoms
  1.  ;;^TOF^
  1.  ;; Criterion F:
  1.  ;;
  1.  ;;   ___ The symptoms described above in Criteria B, C and D cause clinically
  1.  ;;       significant distress or impairment in social, occupational, or other
  1.  ;;       important areas of functioning.
  1.  ;;   ___ The symptoms described above in Criteria B, C and D do NOT cause
  1.  ;;       clinically significant distress or impairment in social, occupational,
  1.  ;;       or other important areas of functioning.
  1.  ;;   ___ No symptoms
  1.  ;;
  1.  Q