DVBCQPT5 ;;ALB-CIOFO/SBW - PTSD QUESTIONNAIRE (v2) ; 14/JUNE/2011
;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
;
TXT ;
;; This form is for use only by VHA, DoD, and VBA staff and contract psychiatrists
;; or psychologists who have been certified to perform Initial PTSD Evaluations.
;; VA will consider the information you provide on this questionnaire as part of
;; their evaluation in processing the Veteran's claim. Please note that this
;; questionnaire is for disability evaluation, not for treatment purposes.
;;
;; 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 Veterans Crisis Line at
;; 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the
;; Veteran to emergency care.
;;
;; 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.
;;
;; SECTION I:
;; ----------
;;
;; 1. Diagnostic Summary
;; This section should be completed based on the current examination and
;; clinical findings.
;;
;; Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria
;; based on today's evaluation?
;; ___ Yes ___ No
;; ICD code: __________
;; 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 does not have a mental disorder that conforms with DSM-IV
;; criteria
;; ___ Veteran has another Axis I and/or II diagnosis. Continue to complete
;; this Questionnaire and/or the Eating Disorders Questionnaire:
;; ______________________________________________________________________
;;
;; 2. Current Diagnoses
;; a. Diagnosis #1: ______________________
;; ICD code: __________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II
;; Comments, if any:_________________________________________________________
;;
;; Diagnosis #2: ______________________
;; ICD code: __________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II
;; Comments, if any:_________________________________________________________
;;
;; Diagnosis #3: ______________________
;; ICD code: __________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II
;; Comments, if any:_________________________________________________________
;;
;; Diagnosis #4: ______________________
;; ICD code: __________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II
;; Comments, if any:_________________________________________________________
;;
;; If additional diagnoses, describe (using above format): _____________________
;;
;; b. Axis III - medical diagnoses (to include TBI): ___________________________
;; ICD code: __________
;; Comments, if any: ___________________________________________________________
;;
;; c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
;; _____________________________________________________________________________
;;
;; d. Axis V - Current global assessment of functioning (GAF) score: ___________
;; Comments, if any: ___________________________________________________________
;;
;; 3. Differentiation of symptoms
;; a. Does the Veteran have more than one Mental disorder diagnosed?
;; ___ Yes ___ No
;; If yes, complete the following question:
;;
;; b. Is it possible to differentiate what symptom(s) is/are attributable to
;; each diagnosis?
;; ___ Yes ___ No ___ Not applicable (N/A)
;; If no, provide reason that it is not possible to differentiate what portion
;; of each symptom is attributable to each diagnosis: __________________________
;; _____________________________________________________________________________
;; If yes, list which symptoms are attributable to each diagnosis: _____________
;; _____________________________________________________________________________
;;
;; c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
;; ___ Yes ___ No ___ Not shown in records reviewed Comments, if any:
;; _____________________________________________________________________________
;; If yes, complete the following question:
;;^TOF^
;; d. Is it possible to differentiate what symptom(s) is/are attributable to
;; each diagnosis?
;; ___ Yes ___ No ___ Not applicable (N/A)
;; If no, provide reason that it is not possible to differentiate what portion
;; of each symptom is attributable to each diagnosis: __________________________
;; _____________________________________________________________________________
;; If yes, list which symptoms are attributable to each diagnosis: _____________
;; _____________________________________________________________________________
;;
;; 4. Occupational and social impairment
;; a. Which of the following best summarizes the Veteran's level of occupational
;; and social impairment with regards to all mental diagnoses?
;; (Check only one)
;; ___ No mental disorder diagnosis
;; ___ 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
;;
;; b. For the indicated level of occupational and social impairment, is it
;; possible to differentiate what portion of the occupational and social
;; impairment indicated above is caused by each mental disorder?
;; ___ Yes ___ No ___ No other mental disorder has been diagnosed
;; If no, provide reason that it is not possible to differentiate what portion
;; of the indicated level of occupational and social impairment is attributable
;; to each diagnosis: __________________________________________________________
;; If yes, list which portion of the indicated level of occupational and social
;; impairment is attributable to each diagnosis: _______________________________
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQPT5 7778 printed Sep 23, 2025@19:24:01 Page 2
DVBCQPT5 ;;ALB-CIOFO/SBW - PTSD QUESTIONNAIRE (v2) ; 14/JUNE/2011
+1 ;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; This form is for use only by VHA, DoD, and VBA staff and contract psychiatrists
+2 ;; or psychologists who have been certified to perform Initial PTSD Evaluations.
+3 ;; VA will consider the information you provide on this questionnaire as part of
+4 ;; their evaluation in processing the Veteran's claim. Please note that this
+5 ;; questionnaire is for disability evaluation, not for treatment purposes.
+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 Veterans Crisis Line at
+10 ;; 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the
+11 ;; Veteran to emergency care.
+12 ;;
+13 ;; In order to conduct an initial examination for PTSD, the examiner must meet
+14 ;; one of the following criteria: a board-certified or board-eligible
+15 ;; psychiatrist; a licensed doctorate-level psychologist; a doctorate-level
+16 ;; mental health provider under the close supervision of a board-certified or
+17 ;; board-eligible psychiatrist or licensed doctorate-level psychologist; a
+18 ;; psychiatry resident under close supervision of a board-certified or board-
+19 ;; eligible psychiatrist or licensed doctorate-level psychologist; or a clinical
+20 ;; or counseling psychologist completing a one-year internship or residency (for
+21 ;; purposes of a doctorate-level degree) under close supervision of a board-
+22 ;; certified or board-eligible psychiatrist or licensed doctorate-level
+23 ;; psychologist.
+24 ;;
+25 ;; SECTION I:
+26 ;; ----------
+27 ;;
+28 ;; 1. Diagnostic Summary
+29 ;; This section should be completed based on the current examination and
+30 ;; clinical findings.
+31 ;;
+32 ;; Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria
+33 ;; based on today's evaluation?
+34 ;; ___ Yes ___ No
+35 ;; ICD code: __________
+36 ;; If no diagnosis of PTSD, check all that apply:
+37 ;; ___ Veteran's symptoms do not meet the diagnostic criteria for PTSD under
+38 ;; DSM-IV criteria
+39 ;; ___ Veteran does not have a mental disorder that conforms with DSM-IV
+40 ;; criteria
+41 ;; ___ Veteran has another Axis I and/or II diagnosis. Continue to complete
+42 ;; this Questionnaire and/or the Eating Disorders Questionnaire:
+43 ;; ______________________________________________________________________
+44 ;;
+45 ;; 2. Current Diagnoses
+46 ;; a. Diagnosis #1: ______________________
+47 ;; ICD code: __________
+48 ;; Indicate the Axis category:
+49 ;; ___ Axis I ___ Axis II
+50 ;; Comments, if any:_________________________________________________________
+51 ;;
+52 ;; Diagnosis #2: ______________________
+53 ;; ICD code: __________
+54 ;; Indicate the Axis category:
+55 ;; ___ Axis I ___ Axis II
+56 ;; Comments, if any:_________________________________________________________
+57 ;;
+58 ;; Diagnosis #3: ______________________
+59 ;; ICD code: __________
+60 ;; Indicate the Axis category:
+61 ;; ___ Axis I ___ Axis II
+62 ;; Comments, if any:_________________________________________________________
+63 ;;
+64 ;; Diagnosis #4: ______________________
+65 ;; ICD code: __________
+66 ;; Indicate the Axis category:
+67 ;; ___ Axis I ___ Axis II
+68 ;; Comments, if any:_________________________________________________________
+69 ;;
+70 ;; If additional diagnoses, describe (using above format): _____________________
+71 ;;
+72 ;; b. Axis III - medical diagnoses (to include TBI): ___________________________
+73 ;; ICD code: __________
+74 ;; Comments, if any: ___________________________________________________________
+75 ;;
+76 ;; c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
+77 ;; _____________________________________________________________________________
+78 ;;
+79 ;; d. Axis V - Current global assessment of functioning (GAF) score: ___________
+80 ;; Comments, if any: ___________________________________________________________
+81 ;;
+82 ;; 3. Differentiation of symptoms
+83 ;; a. Does the Veteran have more than one Mental disorder diagnosed?
+84 ;; ___ Yes ___ No
+85 ;; If yes, complete the following question:
+86 ;;
+87 ;; b. Is it possible to differentiate what symptom(s) is/are attributable to
+88 ;; each diagnosis?
+89 ;; ___ Yes ___ No ___ Not applicable (N/A)
+90 ;; If no, provide reason that it is not possible to differentiate what portion
+91 ;; of each symptom is attributable to each diagnosis: __________________________
+92 ;; _____________________________________________________________________________
+93 ;; If yes, list which symptoms are attributable to each diagnosis: _____________
+94 ;; _____________________________________________________________________________
+95 ;;
+96 ;; c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
+97 ;; ___ Yes ___ No ___ Not shown in records reviewed Comments, if any:
+98 ;; _____________________________________________________________________________
+99 ;; If yes, complete the following question:
+100 ;;^TOF^
+101 ;; d. Is it possible to differentiate what symptom(s) is/are attributable to
+102 ;; each diagnosis?
+103 ;; ___ Yes ___ No ___ Not applicable (N/A)
+104 ;; If no, provide reason that it is not possible to differentiate what portion
+105 ;; of each symptom is attributable to each diagnosis: __________________________
+106 ;; _____________________________________________________________________________
+107 ;; If yes, list which symptoms are attributable to each diagnosis: _____________
+108 ;; _____________________________________________________________________________
+109 ;;
+110 ;; 4. Occupational and social impairment
+111 ;; a. Which of the following best summarizes the Veteran's level of occupational
+112 ;; and social impairment with regards to all mental diagnoses?
+113 ;; (Check only one)
+114 ;; ___ No mental disorder diagnosis
+115 ;; ___ A mental condition has been formally diagnosed, but symptoms are not
+116 ;; severe enough either to interfere with occupational and social functioning
+117 ;; or to require continuous medication
+118 ;; ___ Occupational and social impairment due to mild or transient symptoms which
+119 ;; decrease work efficiency and ability to perform occupational tasks only
+120 ;; during periods of significant stress, or; symptoms controlled by medication
+121 ;; ___ Occupational and social impairment with occasional decrease in work
+122 ;; efficiency and intermittent periods of inability to perform occupational
+123 ;; tasks, although generally functioning satisfactorily, with normal routine
+124 ;; behavior, self-care and conversation
+125 ;; ___ Occupational and social impairment with reduced reliability and
+126 ;; productivity
+127 ;; ___ Occupational and social impairment with deficiencies in most areas, such
+128 ;; as work, school, family relations, judgment, thinking and/or mood
+129 ;; ___ Total occupational and social impairment
+130 ;;
+131 ;; b. For the indicated level of occupational and social impairment, is it
+132 ;; possible to differentiate what portion of the occupational and social
+133 ;; impairment indicated above is caused by each mental disorder?
+134 ;; ___ Yes ___ No ___ No other mental disorder has been diagnosed
+135 ;; If no, provide reason that it is not possible to differentiate what portion
+136 ;; of the indicated level of occupational and social impairment is attributable
+137 ;; to each diagnosis: __________________________________________________________
+138 ;; If yes, list which portion of the indicated level of occupational and social
+139 ;; impairment is attributable to each diagnosis: _______________________________
+140 ;;
+141 QUIT
