DVBCQPT3 ;;ALB-CIOFO/ECF - PTSD QUESTIONNAIRE ; 5/10/2010
;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
;
TXT ;
;;
;; 4. Evidence review
;;
;; In order to provide an accurate medical opinion, the Veteran's records
;; should be reviewed, if available.
;; Was the Veteran's VA claims file reviewed?
;; ___ Yes ___ No
;;
;; If yes, list any records that were reviewed but were not included in the
;; Veteran's VA claims file:
;;
;; ____________________________________________________________________________
;;
;; If no, check all records reviewed as part of this examination:
;; ___ Military service treatment records
;; ___ Military service personnel records
;; ___ Military enlistment examination
;; ___ Military separation examination
;; ___ Military post-deployment questionnaire
;; ___ Department of Defense Form 214 Separation Documents
;; ___ Veterans Health Administration medical records (VA treatment records)
;; ___ Civilian medical records
;; ___ Interviews with collateral witnesses (family and others who have known
;; the veteran before and after military service)
;; ___ Other: ______________________________________
;; ___ No records were reviewed
;;
;; 5. Stressors
;;
;; NOTE: For VA purposes, "fear of hostile military or terrorist activity"
;; means that a veteran experienced, witnessed, or was confronted with an
;; event or circumstance that involved actual or threatened death or serious
;; injury, or a threat to the physical integrity of the veteran or others,
;; such as from an actual or potential improvised explosive device; vehicle-
;; imbedded explosive device; incoming artillery, rocket, or mortar fire;
;; grenade; small arms fire, including suspected sniper fire; or attack upon
;; friendly military aircraft, and the veteran's response to the event or
;; circumstance involved a psychological or psycho-physiological state of
;; fear, helplessness, or horror.
;;^TOF^
;; a. Stressor #1: ___________________
;;
;; Describe circumstance of stressor #1: ______________________________________
;;
;; Are the Veteran's symptoms related to this stressor?
;;
;; ___ Yes ___ No
;;
;; If no, explain: ________________
;;
;; Does this stressor meet Criterion A (i.e., is it adequate to support the
;; diagnosis of PTSD)?
;;
;; ___ Yes ___ No
;;
;; Is the stressor related to the Veteran's fear of hostile military or
;; terrorist activity?
;;
;; ___ Yes ___ No
;;
;; If no, explain: ________________
;;
;; b. Stressor #2: ___________________
;;
;; Describe circumstance of stressor #2: ______________________________________
;;
;; Are the Veteran's symptoms related to this stressor?
;;
;; ___ Yes ___ No
;;
;; If no, explain: ________________
;;^TOF^
;; Does this stressor meet Criterion A (i.e., is it adequate to support the
;; diagnosis of PTSD)?
;;
;; ___ Yes ___ No
;;
;; Is the stressor related to the Veteran's fear of hostile military or
;; terrorist activity?
;;
;; ___ Yes ___ No
;;
;; If no, explain: ________________
;;
;; c. Stressor #3: ___________________
;;
;; Describe circumstance of stressor #3: _______________________
;;
;; Are the Veteran's symptoms related to this stressor?
;;
;; ___ Yes ___ No
;;
;; If no, explain: ________________
;;
;; Does this stressor meet Criterion A (i.e., is it adequate to support the
;; diagnosis of PTSD)?
;;
;; ___ Yes ___ No
;;
;; Is the stressor related to the Veteran's fear of hostile military or
;; terrorist activity?
;;
;; ___ Yes ___ No
;;
;; If no, explain: ________________
;;
;; d. Additional stressors: If additional stressors, describe: ________________
;;^TOF^
;; 6. Symptoms
;;
;; For each level below, check all symptoms that apply.
;;
;; Level I
;;
;; Does the Veteran have any symptoms from the list below?
;;
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;;
;; ___ Depressed mood
;; ___ Anxiety
;; ___ Suspiciousness
;; ___ Panic attacks that occur weekly or less often
;; ___ Chronic sleep impairment
;; ___ Mild memory loss, such as forgetting names, directions or recent events
;;
;;^TOF^
;; Level II
;;
;; Does the Veteran have any symptoms from the list below?
;;
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;;
;; ___ Flattened affect
;; ___ Circumstantial, circumlocutory or stereotyped speech
;; ___ Panic attacks more than once a week
;; ___ Difficulty in understanding complex commands
;; ___ Impairment of short- and long-term memory, for example, retention of
;; only highly learned material, while forgetting to complete tasks
;; ___ Impaired judgment
;; ___ Impaired abstract thinking
;; ___ Disturbances of motivation and mood
;; ___ Difficulty in establishing and maintaining effective work and social
;; relationships
;;
;; Level III
;;
;; Does the Veteran have any symptoms from the list below?
;;
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;;
;; ___ Suicidal ideation
;; ___ Obsessional rituals which interfere with routine activities
;; ___ Speech intermittently illogical, obscure, or irrelevant
;; ___ Near-continuous panic or depression affecting the ability to function
;; independently, appropriately and effectively
;; ___ Impaired impulse control, such as unprovoked irritability with
;; periods of violence
;; ___ Spatial disorientation
;; ___ Neglect of personal appearance and hygiene
;; ___ Difficulty in adapting to stressful circumstances, including work or
;; a worklike setting
;; ___ Inability to establish and maintain effective relationships
;;^TOF^
;; Level IV
;;
;; Does the Veteran have any symptoms from the list below?
;;
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;;
;; ___ Gross impairment in thought processes or communication
;; ___ Persistent delusions or hallucinations
;; ___ Grossly inappropriate behavior
;; ___ Persistent danger of hurting self or others
;; ___ Intermittent inability to perform activities of daily living,
;; including maintenance of minimal personal hygiene
;; ___ Disorientation to time or place
;; ___ Memory loss for names of close relatives, own occupation, or own name
;;
;; 7. 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: __________________________________________________________
;;
;; 8. Differentiation of Symptoms
;;
;; Are you able to differentiate what portion of the symptom complex above is
;; caused by each diagnosis?
;; ___ Yes ___ No
;
;; If yes, list which symptoms are attributable to each diagnosis, where
;; possible: __________________________________________________________________
;;
;;^TOF^
;; 9. Occupational and social impairment
;;
;; Which of the following best represents the Veteran's level of occupational
;; and social impairment?
;; (Check only one)
;;
;; ___ A mental condition has been formally diagnosed, but symptoms are not
;; severe enough either to interfere with occupational and social
;; functioning or to require continuous medication
;; ___ Occupational and social impairment due to mild or transient symptoms
;; which decrease work efficiency and ability to perform occupational
;; tasks only during periods of significant stress, or; symptoms
;; controlled by medication
;; ___ Occupational and social impairment with occasional decrease in work
;; efficiency and intermittent periods of inability to perform
;; occupational tasks, although generally functioning satisfactorily,
;; with normal routine behavior, self-care and conversation
;; ___ Occupational and social impairment with reduced reliability and
;; productivity
;; ___ Occupational and social impairment with deficiencies in most areas,
;; such as work, school, family relations, judgment, thinking and/or
;; mood
;; ___ Total occupational and social impairment
;;
;; 10. Current global assessment of functioning (GAF) score: __________
;;
;; 11. Competency
;;
;; Is the Veteran capable of managing his or her financial affairs?
;;
;; ___ Yes ___ No
;;
;; If no, explain: __________________________
;;
;; 12. Diagnostic testing
;;
;; Has any mental health testing been performed?
;;
;; ___ Yes ___ No
;;
;; If yes, provide dates, types of testing and results: _______________________
;;
;; ____________________________________________________________________________
;;^TOF^
;; 13. Functional impact
;;
;; Does the Veteran's PTSD (and other mental disorders) impact his or her
;; ability to work?
;;
;; ___ Yes ___ No
;;
;; If yes, describe impact, providing one or more examples: ___________________
;;
;; ____________________________________________________________________________
;;
;; 14. Remarks, if any _______________________________________________________
;;
;; ____________________________________________________________________________
;;
;; Psychiatrist/Psychologist signature & title: _______________________________
;;
;; Psychiatrist/Psychologist printed name: ____________________________________
;;
;; Date: ________________________ Phone: ____________________________________
;;
;; License #: _____________
;;
;; Psychiatrist/Psychologist address: _________________________________________
;;
;; 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[HDVBCQPT3 10100 printed Apr 09, 2024@20:53:03 Page 2
DVBCQPT3 ;;ALB-CIOFO/ECF - PTSD QUESTIONNAIRE ; 5/10/2010
+1 ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
+2 ;
TXT ;
+1 ;;
+2 ;; 4. Evidence review
+3 ;;
+4 ;; In order to provide an accurate medical opinion, the Veteran's records
+5 ;; should be reviewed, if available.
+6 ;; Was the Veteran's VA claims file reviewed?
+7 ;; ___ Yes ___ No
+8 ;;
+9 ;; If yes, list any records that were reviewed but were not included in the
+10 ;; Veteran's VA claims file:
+11 ;;
+12 ;; ____________________________________________________________________________
+13 ;;
+14 ;; If no, check all records reviewed as part of this examination:
+15 ;; ___ Military service treatment records
+16 ;; ___ Military service personnel records
+17 ;; ___ Military enlistment examination
+18 ;; ___ Military separation examination
+19 ;; ___ Military post-deployment questionnaire
+20 ;; ___ Department of Defense Form 214 Separation Documents
+21 ;; ___ Veterans Health Administration medical records (VA treatment records)
+22 ;; ___ Civilian medical records
+23 ;; ___ Interviews with collateral witnesses (family and others who have known
+24 ;; the veteran before and after military service)
+25 ;; ___ Other: ______________________________________
+26 ;; ___ No records were reviewed
+27 ;;
+28 ;; 5. Stressors
+29 ;;
+30 ;; NOTE: For VA purposes, "fear of hostile military or terrorist activity"
+31 ;; means that a veteran experienced, witnessed, or was confronted with an
+32 ;; event or circumstance that involved actual or threatened death or serious
+33 ;; injury, or a threat to the physical integrity of the veteran or others,
+34 ;; such as from an actual or potential improvised explosive device; vehicle-
+35 ;; imbedded explosive device; incoming artillery, rocket, or mortar fire;
+36 ;; grenade; small arms fire, including suspected sniper fire; or attack upon
+37 ;; friendly military aircraft, and the veteran's response to the event or
+38 ;; circumstance involved a psychological or psycho-physiological state of
+39 ;; fear, helplessness, or horror.
+40 ;;^TOF^
+41 ;; a. Stressor #1: ___________________
+42 ;;
+43 ;; Describe circumstance of stressor #1: ______________________________________
+44 ;;
+45 ;; Are the Veteran's symptoms related to this stressor?
+46 ;;
+47 ;; ___ Yes ___ No
+48 ;;
+49 ;; If no, explain: ________________
+50 ;;
+51 ;; Does this stressor meet Criterion A (i.e., is it adequate to support the
+52 ;; diagnosis of PTSD)?
+53 ;;
+54 ;; ___ Yes ___ No
+55 ;;
+56 ;; Is the stressor related to the Veteran's fear of hostile military or
+57 ;; terrorist activity?
+58 ;;
+59 ;; ___ Yes ___ No
+60 ;;
+61 ;; If no, explain: ________________
+62 ;;
+63 ;; b. Stressor #2: ___________________
+64 ;;
+65 ;; Describe circumstance of stressor #2: ______________________________________
+66 ;;
+67 ;; Are the Veteran's symptoms related to this stressor?
+68 ;;
+69 ;; ___ Yes ___ No
+70 ;;
+71 ;; If no, explain: ________________
+72 ;;^TOF^
+73 ;; Does this stressor meet Criterion A (i.e., is it adequate to support the
+74 ;; diagnosis of PTSD)?
+75 ;;
+76 ;; ___ Yes ___ No
+77 ;;
+78 ;; Is the stressor related to the Veteran's fear of hostile military or
+79 ;; terrorist activity?
+80 ;;
+81 ;; ___ Yes ___ No
+82 ;;
+83 ;; If no, explain: ________________
+84 ;;
+85 ;; c. Stressor #3: ___________________
+86 ;;
+87 ;; Describe circumstance of stressor #3: _______________________
+88 ;;
+89 ;; Are the Veteran's symptoms related to this stressor?
+90 ;;
+91 ;; ___ Yes ___ No
+92 ;;
+93 ;; If no, explain: ________________
+94 ;;
+95 ;; Does this stressor meet Criterion A (i.e., is it adequate to support the
+96 ;; diagnosis of PTSD)?
+97 ;;
+98 ;; ___ Yes ___ No
+99 ;;
+100 ;; Is the stressor related to the Veteran's fear of hostile military or
+101 ;; terrorist activity?
+102 ;;
+103 ;; ___ Yes ___ No
+104 ;;
+105 ;; If no, explain: ________________
+106 ;;
+107 ;; d. Additional stressors: If additional stressors, describe: ________________
+108 ;;^TOF^
+109 ;; 6. Symptoms
+110 ;;
+111 ;; For each level below, check all symptoms that apply.
+112 ;;
+113 ;; Level I
+114 ;;
+115 ;; Does the Veteran have any symptoms from the list below?
+116 ;;
+117 ;; ___ Yes ___ No
+118 ;;
+119 ;; If yes, check all that apply:
+120 ;;
+121 ;; ___ Depressed mood
+122 ;; ___ Anxiety
+123 ;; ___ Suspiciousness
+124 ;; ___ Panic attacks that occur weekly or less often
+125 ;; ___ Chronic sleep impairment
+126 ;; ___ Mild memory loss, such as forgetting names, directions or recent events
+127 ;;
+128 ;;^TOF^
+129 ;; Level II
+130 ;;
+131 ;; Does the Veteran have any symptoms from the list below?
+132 ;;
+133 ;; ___ Yes ___ No
+134 ;;
+135 ;; If yes, check all that apply:
+136 ;;
+137 ;; ___ Flattened affect
+138 ;; ___ Circumstantial, circumlocutory or stereotyped speech
+139 ;; ___ Panic attacks more than once a week
+140 ;; ___ Difficulty in understanding complex commands
+141 ;; ___ Impairment of short- and long-term memory, for example, retention of
+142 ;; only highly learned material, while forgetting to complete tasks
+143 ;; ___ Impaired judgment
+144 ;; ___ Impaired abstract thinking
+145 ;; ___ Disturbances of motivation and mood
+146 ;; ___ Difficulty in establishing and maintaining effective work and social
+147 ;; relationships
+148 ;;
+149 ;; Level III
+150 ;;
+151 ;; Does the Veteran have any symptoms from the list below?
+152 ;;
+153 ;; ___ Yes ___ No
+154 ;;
+155 ;; If yes, check all that apply:
+156 ;;
+157 ;; ___ Suicidal ideation
+158 ;; ___ Obsessional rituals which interfere with routine activities
+159 ;; ___ Speech intermittently illogical, obscure, or irrelevant
+160 ;; ___ Near-continuous panic or depression affecting the ability to function
+161 ;; independently, appropriately and effectively
+162 ;; ___ Impaired impulse control, such as unprovoked irritability with
+163 ;; periods of violence
+164 ;; ___ Spatial disorientation
+165 ;; ___ Neglect of personal appearance and hygiene
+166 ;; ___ Difficulty in adapting to stressful circumstances, including work or
+167 ;; a worklike setting
+168 ;; ___ Inability to establish and maintain effective relationships
+169 ;;^TOF^
+170 ;; Level IV
+171 ;;
+172 ;; Does the Veteran have any symptoms from the list below?
+173 ;;
+174 ;; ___ Yes ___ No
+175 ;;
+176 ;; If yes, check all that apply:
+177 ;;
+178 ;; ___ Gross impairment in thought processes or communication
+179 ;; ___ Persistent delusions or hallucinations
+180 ;; ___ Grossly inappropriate behavior
+181 ;; ___ Persistent danger of hurting self or others
+182 ;; ___ Intermittent inability to perform activities of daily living,
+183 ;; including maintenance of minimal personal hygiene
+184 ;; ___ Disorientation to time or place
+185 ;; ___ Memory loss for names of close relatives, own occupation, or own name
+186 ;;
+187 ;; 7. Other symptoms
+188 ;;
+189 ;; Does the Veteran have any other symptoms attributable to PTSD (and other
+190 ;; mental disorders) that are not listed above?
+191 ;;
+192 ;; ___ Yes ___ No
+193 ;;
+194 ;; If yes, describe: __________________________________________________________
+195 ;;
+196 ;; 8. Differentiation of Symptoms
+197 ;;
+198 ;; Are you able to differentiate what portion of the symptom complex above is
+199 ;; caused by each diagnosis?
+200 ;; ___ Yes ___ No
+201 ;
+202 ;; If yes, list which symptoms are attributable to each diagnosis, where
+203 ;; possible: __________________________________________________________________
+204 ;;
+205 ;;^TOF^
+206 ;; 9. Occupational and social impairment
+207 ;;
+208 ;; Which of the following best represents the Veteran's level of occupational
+209 ;; and social impairment?
+210 ;; (Check only one)
+211 ;;
+212 ;; ___ A mental condition has been formally diagnosed, but symptoms are not
+213 ;; severe enough either to interfere with occupational and social
+214 ;; functioning or to require continuous medication
+215 ;; ___ Occupational and social impairment due to mild or transient symptoms
+216 ;; which decrease work efficiency and ability to perform occupational
+217 ;; tasks only during periods of significant stress, or; symptoms
+218 ;; controlled by medication
+219 ;; ___ Occupational and social impairment with occasional decrease in work
+220 ;; efficiency and intermittent periods of inability to perform
+221 ;; occupational tasks, although generally functioning satisfactorily,
+222 ;; with normal routine behavior, self-care and conversation
+223 ;; ___ Occupational and social impairment with reduced reliability and
+224 ;; productivity
+225 ;; ___ Occupational and social impairment with deficiencies in most areas,
+226 ;; such as work, school, family relations, judgment, thinking and/or
+227 ;; mood
+228 ;; ___ Total occupational and social impairment
+229 ;;
+230 ;; 10. Current global assessment of functioning (GAF) score: __________
+231 ;;
+232 ;; 11. Competency
+233 ;;
+234 ;; Is the Veteran capable of managing his or her financial affairs?
+235 ;;
+236 ;; ___ Yes ___ No
+237 ;;
+238 ;; If no, explain: __________________________
+239 ;;
+240 ;; 12. Diagnostic testing
+241 ;;
+242 ;; Has any mental health testing been performed?
+243 ;;
+244 ;; ___ Yes ___ No
+245 ;;
+246 ;; If yes, provide dates, types of testing and results: _______________________
+247 ;;
+248 ;; ____________________________________________________________________________
+249 ;;^TOF^
+250 ;; 13. Functional impact
+251 ;;
+252 ;; Does the Veteran's PTSD (and other mental disorders) impact his or her
+253 ;; ability to work?
+254 ;;
+255 ;; ___ Yes ___ No
+256 ;;
+257 ;; If yes, describe impact, providing one or more examples: ___________________
+258 ;;
+259 ;; ____________________________________________________________________________
+260 ;;
+261 ;; 14. Remarks, if any _______________________________________________________
+262 ;;
+263 ;; ____________________________________________________________________________
+264 ;;
+265 ;; Psychiatrist/Psychologist signature & title: _______________________________
+266 ;;
+267 ;; Psychiatrist/Psychologist printed name: ____________________________________
+268 ;;
+269 ;; Date: ________________________ Phone: ____________________________________
+270 ;;
+271 ;; License #: _____________
+272 ;;
+273 ;; Psychiatrist/Psychologist address: _________________________________________
+274 ;;
+275 ;; NOTE: VA may request additional medical information, including additional
+276 ;; examinations if necessary to complete VA's review of the Veteran's
+277 ;; application.
+278 ;;
+279 ;;^END^
+280 QUIT
