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Routine: DVBCQPT3

DVBCQPT3.m

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  1. DVBCQPT3 ;;ALB-CIOFO/ECF - PTSD QUESTIONNAIRE ; 5/10/2010
  1. ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
  1. ;
  1. TXT ;
  1. ;;
  1. ;; 4. Evidence review
  1. ;;
  1. ;; In order to provide an accurate medical opinion, the Veteran's records
  1. ;; should be reviewed, if available.
  1. ;; Was the Veteran's VA claims file reviewed?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, list any records that were reviewed but were not included in the
  1. ;; Veteran's VA claims file:
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; If no, check all records reviewed as part of this examination:
  1. ;; ___ Military service treatment records
  1. ;; ___ Military service personnel records
  1. ;; ___ Military enlistment examination
  1. ;; ___ Military separation examination
  1. ;; ___ Military post-deployment questionnaire
  1. ;; ___ Department of Defense Form 214 Separation Documents
  1. ;; ___ Veterans Health Administration medical records (VA treatment records)
  1. ;; ___ Civilian medical records
  1. ;; ___ Interviews with collateral witnesses (family and others who have known
  1. ;; the veteran before and after military service)
  1. ;; ___ Other: ______________________________________
  1. ;; ___ No records were reviewed
  1. ;;
  1. ;; 5. Stressors
  1. ;;
  1. ;; NOTE: For VA purposes, "fear of hostile military or terrorist activity"
  1. ;; means that a veteran experienced, witnessed, or was confronted with an
  1. ;; event or circumstance that involved actual or threatened death or serious
  1. ;; injury, or a threat to the physical integrity of the veteran or others,
  1. ;; such as from an actual or potential improvised explosive device; vehicle-
  1. ;; imbedded explosive device; incoming artillery, rocket, or mortar fire;
  1. ;; grenade; small arms fire, including suspected sniper fire; or attack upon
  1. ;; friendly military aircraft, and the veteran's response to the event or
  1. ;; circumstance involved a psychological or psycho-physiological state of
  1. ;; fear, helplessness, or horror.
  1. ;;^TOF^
  1. ;; a. Stressor #1: ___________________
  1. ;;
  1. ;; Describe circumstance of stressor #1: ______________________________________
  1. ;;
  1. ;; Are the Veteran's symptoms related to this stressor?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, explain: ________________
  1. ;;
  1. ;; Does this stressor meet Criterion A (i.e., is it adequate to support the
  1. ;; diagnosis of PTSD)?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; Is the stressor related to the Veteran's fear of hostile military or
  1. ;; terrorist activity?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, explain: ________________
  1. ;;
  1. ;; b. Stressor #2: ___________________
  1. ;;
  1. ;; Describe circumstance of stressor #2: ______________________________________
  1. ;;
  1. ;; Are the Veteran's symptoms related to this stressor?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, explain: ________________
  1. ;;^TOF^
  1. ;; Does this stressor meet Criterion A (i.e., is it adequate to support the
  1. ;; diagnosis of PTSD)?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; Is the stressor related to the Veteran's fear of hostile military or
  1. ;; terrorist activity?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, explain: ________________
  1. ;;
  1. ;; c. Stressor #3: ___________________
  1. ;;
  1. ;; Describe circumstance of stressor #3: _______________________
  1. ;;
  1. ;; Are the Veteran's symptoms related to this stressor?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, explain: ________________
  1. ;;
  1. ;; Does this stressor meet Criterion A (i.e., is it adequate to support the
  1. ;; diagnosis of PTSD)?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; Is the stressor related to the Veteran's fear of hostile military or
  1. ;; terrorist activity?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, explain: ________________
  1. ;;
  1. ;; d. Additional stressors: If additional stressors, describe: ________________
  1. ;;^TOF^
  1. ;; 6. Symptoms
  1. ;;
  1. ;; For each level below, check all symptoms that apply.
  1. ;;
  1. ;; Level I
  1. ;;
  1. ;; Does the Veteran have any symptoms from the list below?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, check all that apply:
  1. ;;
  1. ;; ___ Depressed mood
  1. ;; ___ Anxiety
  1. ;; ___ Suspiciousness
  1. ;; ___ Panic attacks that occur weekly or less often
  1. ;; ___ Chronic sleep impairment
  1. ;; ___ Mild memory loss, such as forgetting names, directions or recent events
  1. ;;
  1. ;;^TOF^
  1. ;; Level II
  1. ;;
  1. ;; Does the Veteran have any symptoms from the list below?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, check all that apply:
  1. ;;
  1. ;; ___ Flattened affect
  1. ;; ___ Circumstantial, circumlocutory or stereotyped speech
  1. ;; ___ Panic attacks more than once a week
  1. ;; ___ Difficulty in understanding complex commands
  1. ;; ___ Impairment of short- and long-term memory, for example, retention of
  1. ;; only highly learned material, while forgetting to complete tasks
  1. ;; ___ Impaired judgment
  1. ;; ___ Impaired abstract thinking
  1. ;; ___ Disturbances of motivation and mood
  1. ;; ___ Difficulty in establishing and maintaining effective work and social
  1. ;; relationships
  1. ;;
  1. ;; Level III
  1. ;;
  1. ;; Does the Veteran have any symptoms from the list below?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, check all that apply:
  1. ;;
  1. ;; ___ Suicidal ideation
  1. ;; ___ Obsessional rituals which interfere with routine activities
  1. ;; ___ Speech intermittently illogical, obscure, or irrelevant
  1. ;; ___ Near-continuous panic or depression affecting the ability to function
  1. ;; independently, appropriately and effectively
  1. ;; ___ Impaired impulse control, such as unprovoked irritability with
  1. ;; periods of violence
  1. ;; ___ Spatial disorientation
  1. ;; ___ Neglect of personal appearance and hygiene
  1. ;; ___ Difficulty in adapting to stressful circumstances, including work or
  1. ;; a worklike setting
  1. ;; ___ Inability to establish and maintain effective relationships
  1. ;;^TOF^
  1. ;; Level IV
  1. ;;
  1. ;; Does the Veteran have any symptoms from the list below?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, check all that apply:
  1. ;;
  1. ;; ___ Gross impairment in thought processes or communication
  1. ;; ___ Persistent delusions or hallucinations
  1. ;; ___ Grossly inappropriate behavior
  1. ;; ___ Persistent danger of hurting self or others
  1. ;; ___ Intermittent inability to perform activities of daily living,
  1. ;; including maintenance of minimal personal hygiene
  1. ;; ___ Disorientation to time or place
  1. ;; ___ Memory loss for names of close relatives, own occupation, or own name
  1. ;;
  1. ;; 7. 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. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, describe: __________________________________________________________
  1. ;;
  1. ;; 8. Differentiation of Symptoms
  1. ;;
  1. ;; Are you able to differentiate what portion of the symptom complex above is
  1. ;; caused by each diagnosis?
  1. ;; ___ Yes ___ No
  1. ;
  1. ;; If yes, list which symptoms are attributable to each diagnosis, where
  1. ;; possible: __________________________________________________________________
  1. ;;
  1. ;;^TOF^
  1. ;; 9. Occupational and social impairment
  1. ;;
  1. ;; Which of the following best represents the Veteran's level of occupational
  1. ;; and social impairment?
  1. ;; (Check only one)
  1. ;;
  1. ;; ___ A mental condition has been formally diagnosed, but symptoms are not
  1. ;; severe enough either to interfere with occupational and social
  1. ;; functioning or to require continuous medication
  1. ;; ___ Occupational and social impairment due to mild or transient symptoms
  1. ;; which decrease work efficiency and ability to perform occupational
  1. ;; tasks only during periods of significant stress, or; symptoms
  1. ;; controlled by medication
  1. ;; ___ Occupational and social impairment with occasional decrease in work
  1. ;; efficiency and intermittent periods of inability to perform
  1. ;; occupational tasks, although generally functioning satisfactorily,
  1. ;; with normal routine behavior, self-care and conversation
  1. ;; ___ Occupational and social impairment with reduced reliability and
  1. ;; productivity
  1. ;; ___ Occupational and social impairment with deficiencies in most areas,
  1. ;; such as work, school, family relations, judgment, thinking and/or
  1. ;; mood
  1. ;; ___ Total occupational and social impairment
  1. ;;
  1. ;; 10. Current global assessment of functioning (GAF) score: __________
  1. ;;
  1. ;; 11. Competency
  1. ;;
  1. ;; Is the Veteran capable of managing his or her financial affairs?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, explain: __________________________
  1. ;;
  1. ;; 12. Diagnostic testing
  1. ;;
  1. ;; Has any mental health testing been performed?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, provide dates, types of testing and results: _______________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;^TOF^
  1. ;; 13. Functional impact
  1. ;;
  1. ;; Does the Veteran's PTSD (and other mental disorders) impact his or her
  1. ;; ability to work?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, describe impact, providing one or more examples: ___________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; 14. Remarks, if any _______________________________________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; Psychiatrist/Psychologist signature & title: _______________________________
  1. ;;
  1. ;; Psychiatrist/Psychologist printed name: ____________________________________
  1. ;;
  1. ;; Date: ________________________ Phone: ____________________________________
  1. ;;
  1. ;; License #: _____________
  1. ;;
  1. ;; Psychiatrist/Psychologist address: _________________________________________
  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. ;;
  1. ;;^END^
  1. Q