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Routine: DVBCQPT5

DVBCQPT5.m

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  1. DVBCQPT5 ;;ALB-CIOFO/SBW - PTSD QUESTIONNAIRE (v2) ; 14/JUNE/2011
  1. ;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
  1. ;
  1. TXT ;
  1. ;; This form is for use only by VHA, DoD, and VBA staff and contract psychiatrists
  1. ;; or psychologists who have been certified to perform Initial PTSD Evaluations.
  1. ;; VA will consider the information you provide on this questionnaire as part of
  1. ;; their evaluation in processing the Veteran's claim. Please note that this
  1. ;; questionnaire is for disability evaluation, not for treatment purposes.
  1. ;;
  1. ;; NOTE: If the Veteran experiences a mental health emergency during the
  1. ;; interview, please terminate the interview and obtain help, using local
  1. ;; resources as appropriate. You may also contact the Veterans Crisis Line at
  1. ;; 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the
  1. ;; Veteran to emergency care.
  1. ;;
  1. ;; In order to conduct an initial examination for PTSD, the examiner must meet
  1. ;; one of the following criteria: a board-certified or board-eligible
  1. ;; psychiatrist; a licensed doctorate-level psychologist; a doctorate-level
  1. ;; mental health provider under the close supervision of a board-certified or
  1. ;; board-eligible psychiatrist or licensed doctorate-level psychologist; a
  1. ;; psychiatry resident under close supervision of a board-certified or board-
  1. ;; eligible psychiatrist or licensed doctorate-level psychologist; or a clinical
  1. ;; or counseling psychologist completing a one-year internship or residency (for
  1. ;; purposes of a doctorate-level degree) under close supervision of a board-
  1. ;; certified or board-eligible psychiatrist or licensed doctorate-level
  1. ;; psychologist.
  1. ;;
  1. ;; SECTION I:
  1. ;; ----------
  1. ;;
  1. ;; 1. Diagnostic Summary
  1. ;; This section should be completed based on the current examination and
  1. ;; clinical findings.
  1. ;;
  1. ;; Does the Veteran have a diagnosis of PTSD that conforms to DSM-IV criteria
  1. ;; based on today's evaluation?
  1. ;; ___ Yes ___ No
  1. ;; ICD code: __________
  1. ;; If no diagnosis of PTSD, check all that apply:
  1. ;; ___ Veteran's symptoms do not meet the diagnostic criteria for PTSD under
  1. ;; DSM-IV criteria
  1. ;; ___ Veteran does not have a mental disorder that conforms with DSM-IV
  1. ;; criteria
  1. ;; ___ Veteran has another Axis I and/or II diagnosis. Continue to complete
  1. ;; this Questionnaire and/or the Eating Disorders Questionnaire:
  1. ;; ______________________________________________________________________
  1. ;;
  1. ;; 2. Current Diagnoses
  1. ;; a. Diagnosis #1: ______________________
  1. ;; ICD code: __________
  1. ;; Indicate the Axis category:
  1. ;; ___ Axis I ___ Axis II
  1. ;; Comments, if any:_________________________________________________________
  1. ;;
  1. ;; Diagnosis #2: ______________________
  1. ;; ICD code: __________
  1. ;; Indicate the Axis category:
  1. ;; ___ Axis I ___ Axis II
  1. ;; Comments, if any:_________________________________________________________
  1. ;;
  1. ;; Diagnosis #3: ______________________
  1. ;; ICD code: __________
  1. ;; Indicate the Axis category:
  1. ;; ___ Axis I ___ Axis II
  1. ;; Comments, if any:_________________________________________________________
  1. ;;
  1. ;; Diagnosis #4: ______________________
  1. ;; ICD code: __________
  1. ;; Indicate the Axis category:
  1. ;; ___ Axis I ___ Axis II
  1. ;; Comments, if any:_________________________________________________________
  1. ;;
  1. ;; If additional diagnoses, describe (using above format): _____________________
  1. ;;
  1. ;; b. Axis III - medical diagnoses (to include TBI): ___________________________
  1. ;; ICD code: __________
  1. ;; Comments, if any: ___________________________________________________________
  1. ;;
  1. ;; c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
  1. ;; _____________________________________________________________________________
  1. ;;
  1. ;; d. Axis V - Current global assessment of functioning (GAF) score: ___________
  1. ;; Comments, if any: ___________________________________________________________
  1. ;;
  1. ;; 3. Differentiation of symptoms
  1. ;; a. Does the Veteran have more than one Mental disorder diagnosed?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following question:
  1. ;;
  1. ;; b. Is it possible to differentiate what symptom(s) is/are attributable to
  1. ;; each diagnosis?
  1. ;; ___ Yes ___ No ___ Not applicable (N/A)
  1. ;; If no, provide reason that it is not possible to differentiate what portion
  1. ;; of each symptom is attributable to each diagnosis: __________________________
  1. ;; _____________________________________________________________________________
  1. ;; If yes, list which symptoms are attributable to each diagnosis: _____________
  1. ;; _____________________________________________________________________________
  1. ;;
  1. ;; c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
  1. ;; ___ Yes ___ No ___ Not shown in records reviewed Comments, if any:
  1. ;; _____________________________________________________________________________
  1. ;; If yes, complete the following question:
  1. ;;^TOF^
  1. ;; d. Is it possible to differentiate what symptom(s) is/are attributable to
  1. ;; each diagnosis?
  1. ;; ___ Yes ___ No ___ Not applicable (N/A)
  1. ;; If no, provide reason that it is not possible to differentiate what portion
  1. ;; of each symptom is attributable to each diagnosis: __________________________
  1. ;; _____________________________________________________________________________
  1. ;; If yes, list which symptoms are attributable to each diagnosis: _____________
  1. ;; _____________________________________________________________________________
  1. ;;
  1. ;; 4. Occupational and social impairment
  1. ;; a. Which of the following best summarizes the Veteran's level of occupational
  1. ;; and social impairment with regards to all mental diagnoses?
  1. ;; (Check only one)
  1. ;; ___ No mental disorder diagnosis
  1. ;; ___ A mental condition has been formally diagnosed, but symptoms are not
  1. ;; severe enough either to interfere with occupational and social functioning
  1. ;; or to require continuous medication
  1. ;; ___ Occupational and social impairment due to mild or transient symptoms which
  1. ;; decrease work efficiency and ability to perform occupational tasks only
  1. ;; during periods of significant stress, or; symptoms controlled by medication
  1. ;; ___ Occupational and social impairment with occasional decrease in work
  1. ;; efficiency and intermittent periods of inability to perform occupational
  1. ;; tasks, although generally functioning satisfactorily, with normal routine
  1. ;; 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, such
  1. ;; as work, school, family relations, judgment, thinking and/or mood
  1. ;; ___ Total occupational and social impairment
  1. ;;
  1. ;; b. For the indicated level of occupational and social impairment, is it
  1. ;; possible to differentiate what portion of the occupational and social
  1. ;; impairment indicated above is caused by each mental disorder?
  1. ;; ___ Yes ___ No ___ No other mental disorder has been diagnosed
  1. ;; If no, provide reason that it is not possible to differentiate what portion
  1. ;; of the indicated level of occupational and social impairment is attributable
  1. ;; to each diagnosis: __________________________________________________________
  1. ;; If yes, list which portion of the indicated level of occupational and social
  1. ;; impairment is attributable to each diagnosis: _______________________________
  1. ;;
  1. Q