- 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 Feb 18, 2025@23:14:22 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