- 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 Jan 18, 2025@02:49:12 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