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Routine: DVBCQPT6

DVBCQPT6.m

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  1. DVBCQPT6 ;;ALB-CIOFO/SBW - PTSD QUESTIONNAIRE (v2) ; 14/JUNE/2011
  1.  ;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; c. If a diagnosis of TBI exists, is it possible to differentiate what portion
  1.  ;; of the occupational and social impairment indicated above is caused by the TBI?
  1.  ;; ___ Yes   ___ No  ___ No diagnosis of TBI
  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.  ;;^TOF^
  1.  ;;                                 SECTION II:
  1.  ;;                                 -----------  
  1.  ;;                              Clinical Findings:
  1.  ;;                              ------------------
  1.  ;;
  1.  ;; 1. Evidence review
  1.  ;; In order to provide an accurate medical opinion, the Veteran's claims folder
  1.  ;; must be reviewed.
  1.  ;; a. Records reviewed (check all that apply):
  1.  ;; ___  Claims folder (C-file):
  1.  ;;      ___ Yes
  1.  ;;      ___ No
  1.  ;;      If no, provide reason C-file was not reviewed: _________________________
  1.  ;; ___ Other, please describe: _________________________________________________
  1.  ;; ___ No records were reviewed
  1.  ;;
  1.  ;; b. Was pertinent information from collateral sources reviewed?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe: ___________________________________________________________
  1.  ;;
  1.  ;; 2. History
  1.  ;; a. Relevant Social/Marital/Family history (pre-military, military, and post-
  1.  ;; military): __________________________________________________________________
  1.  ;;
  1.  ;; b. Relevant Occupational and Educational history (pre-military, military, and
  1.  ;; post-military): _____________________________________________________________
  1.  ;;
  1.  ;; c. Relevant Mental Health history, to include prescribed medications and
  1.  ;; family mental health (pre-military, military, and post-military: ____________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; d. Relevant Legal and Behavioral history (pre-military, military, and post-
  1.  ;; military): __________________________________________________________________
  1.  ;;
  1.  ;; e. Relevant Substance abuse history (pre-military, military, and post-
  1.  ;; military): __________________________________________________________________
  1.  ;;
  1.  ;; f. Sentinel Event(s) (other than stressors): ________________________________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; g. Other, if any: ___________________________________________________________
  1.  ;;^TOF^
  1.  ;; 3. Stressors
  1.  ;; The stressful event can be due to combat, personal trauma, other life
  1.  ;; threatening situations (non-combat related stressors).
  1.  ;; NOTE: For VA purposes, "fear of hostile military or terrorist activity" means
  1.  ;; that a veteran experienced, witnessed, or was confronted with an event or
  1.  ;; circumstance that involved actual or threatened death or serious injury, or
  1.  ;; a threat to the physical integrity of the veteran or others, such as from an 
  1.  ;; actual or potential improvised explosive device; vehicle-imbedded explosive
  1.  ;; device; incoming artillery, rocket, or mortar fire; grenade; small arms fire,
  1.  ;; including suspected sniper fire; or attack upon friendly military aircraft,
  1.  ;; and the veteran's response to the event or circumstance involved a
  1.  ;; psychological or psycho-physiological state of fear, helplessness, or horror.
  1.  ;;
  1.  ;; Describe one or more specific stressor event (s) the Veteran considers
  1.  ;; traumatic (may be pre-military, military, or post-military):
  1.  ;;
  1.  ;; a. Stressor #1: ___________________
  1.  ;; Does this stressor meet Criterion A (i.e., is it adequate to support the
  1.  ;; diagnosis of PTSD)?
  1.  ;; ___ Yes   ___ No
  1.  ;; Is the stressor related to the Veteran's fear of hostile military or terrorist
  1.  ;; activity?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If no, explain: _________________________________________________________
  1.  ;;
  1.  ;; b. Stressor #2: ___________________
  1.  ;; Does this stressor meet Criterion A (i.e., is it adequate to support the
  1.  ;; diagnosis of PTSD)?
  1.  ;; ___ Yes   ___ No
  1.  ;; Is the stressor related to the Veteran's fear of hostile military or terrorist
  1.  ;; activity?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If no, explain: _________________________________________________________
  1.  ;;
  1.  ;; c. Stressor #3: ___________________
  1.  ;; Does this stressor meet Criterion A (i.e., is it adequate to support the
  1.  ;; diagnosis of PTSD)?
  1.  ;; ___ Yes   ___ No
  1.  ;; Is the stressor related to the Veteran's fear of hostile military or terrorist
  1.  ;; activity?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If no, explain: _________________________________________________________
  1.  ;;
  1.  ;; d. Additional stressors: If additional stressors, describe (list using the
  1.  ;; above sequential format): ___________________________________________________ 
  1.  ;;^TOF^
  1.  ;; 4. PTSD Diagnostic Criteria
  1.  ;; a. Please check criteria used for establishing the current PTSD diagnosis.
  1.  ;; The diagnostic criteria for PTSD, referred to as Criteria A-F, are from the
  1.  ;; Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).
  1.  ;;
  1.  ;; Criterion A: The Veteran has been exposed to a traumatic event where both of
  1.  ;; the following were present:
  1.  ;;    ___ The Veteran experienced, witnessed or was confronted with an event
  1.  ;;        that involved actual or threatened death or serious injury, or a
  1.  ;;        threat to the physical integrity of self or others.
  1.  ;;    ___ The Veteran's response involved intense fear, helplessness or horror.
  1.  ;;    ___ No exposure to a traumatic event.
  1.  ;;
  1.  ;; Criterion B: The traumatic event is persistently reexperienced in 1 or more
  1.  ;; of the following ways:
  1.  ;;    ___ Recurrent and distressing recollections of the event, including images,
  1.  ;;        thoughts or perceptions
  1.  ;;    ___ Recurrent distressing dreams of the event
  1.  ;;    ___ Acting or feeling as if the traumatic event were recurring; this
  1.  ;;        includes a sense of reliving the experience, illusions, hallucinations
  1.  ;;        and dissociative flashback episodes, including those that occur on
  1.  ;;        awakening or when intoxicated
  1.  ;;    ___ Intense psychological distress at exposure to internal or external cues
  1.  ;;        that symbolize or resemble an aspect of the traumatic event
  1.  ;;    ___ Physiological reactivity on exposure to internal or external cues that
  1.  ;;        symbolize or resemble an aspect of the traumatic event
  1.  ;;    ___ The traumatic event is not persistently reexperienced
  1.  ;;
  1.  ;; Criterion C: Persistent avoidance of stimuli associated with the trauma and
  1.  ;; numbing of general responsiveness (not present before the trauma), as
  1.  ;; indicated by 3 or more of the following:
  1.  ;;    ___ Efforts to avoid thoughts, feelings or conversations associated with
  1.  ;;        the trauma
  1.  ;;    ___ Efforts to avoid activities, places or people that arouse recollections
  1.  ;;        of the trauma
  1.  ;;    ___ Inability to recall an important aspect of the trauma
  1.  ;;    ___ Markedly diminished interest or participation in significant activities
  1.  ;;    ___ Feeling of detachment or estrangement from others
  1.  ;;    ___ Restricted range of affect (e.g., unable to have loving feelings)
  1.  ;;    ___ Sense of a foreshortened future (e.g., does not expect to have a career,
  1.  ;;        marriage, children or a normal life span)
  1.  ;;    ___ No persistent avoidance of stimuli associated with the trauma or numbing
  1.  ;;        of general  responsiveness
  1.  ;;^TOF^
  1.  ;; Criterion D: Persistent symptoms of increased arousal, not present before the
  1.  ;; trauma, as indicated by 2 or more of the following:
  1.  ;;    ___ Difficulty falling or staying asleep
  1.  ;;    ___ Irritability or outbursts of anger
  1.  ;;    ___ Difficulty concentrating
  1.  ;;    ___ Hypervigilance
  1.  ;;    ___ Exaggerated startle response
  1.  ;;    ___ No persistent symptoms of increased arousal
  1.  ;;
  1.  ;; Criterion E:
  1.  ;;    ___ The duration of the symptoms described above in Criteria B, C and D
  1.  ;;        is more than 1 month.
  1.  ;;    ___ The duration of the symptoms described above in Criteria B, C and D
  1.  ;;        is less than 1 month.
  1.  ;;    ___ Veteran does not meet full criteria for PTSD
  1.  ;;
  1.  ;; Criterion F:
  1.  ;;    ___ The PTSD symptoms described above cause clinically significant distress
  1.  ;;        or impairment in social, occupational, or other important areas of
  1.  ;;        functioning.
  1.  ;;    ___ The PTSD symptoms described above do NOT cause clinically significant
  1.  ;;        distress or impairment in social, occupational, or other important areas
  1.  ;;        of functioning.
  1.  ;;    ___ Veteran does not meet full criteria for PTSD
  1.  ;;
  1.  ;; b. Which stressor(s) contributed to the Veteran's PTSD diagnosis?:
  1.  ;;    ___ Stressor #1
  1.  ;;    ___ Stressor #2
  1.  ;;    ___ Stressor #3
  1.  ;;    ___ Other, please indicate stressor number (i.e. stressor #4, #5, etc.) as
  1.  ;;        indicated above): ____________________________________________________
  1.  ;;^TOF^
  1.  ;; 5. Symptoms
  1.  ;; For VA rating purposes, check all symptoms that apply to the Veteran's
  1.  ;; diagnoses:
  1.  ;;    ___ Depressed mood
  1.  ;;    ___ Anxiety
  1.  ;;    ___ Suspiciousness
  1.  ;;    ___ Panic attacks that occur weekly or less often
  1.  ;;    ___ Panic attacks more than once a week
  1.  ;;    ___ Near-continuous panic or depression affecting the ability to function
  1.  ;;        independently, appropriately and effectively
  1.  ;;    ___ Chronic sleep impairment
  1.  ;;    ___ Mild memory loss, such as forgetting names, directions or recent events
  1.  ;;    ___ Impairment of short- and long-term memory, for example, retention of
  1.  ;;        only highly learned material, while forgetting to complete tasks
  1.  ;;    ___ Memory loss for names of close relatives, own occupation, or own name
  1.  ;;    ___ Flattened affect
  1.  ;;    ___ Circumstantial, circumlocutory or stereotyped speech
  1.  ;;    ___ Speech intermittently illogical, obscure, or irrelevant
  1.  ;;    ___ Difficulty in understanding complex commands
  1.  ;;    ___ Impaired judgment
  1.  ;;    ___ Impaired abstract thinking
  1.  ;;    ___ Gross impairment in thought processes or communication
  1.  ;;    ___ Disturbances of motivation and mood
  1.  ;;    ___ Difficulty in establishing and maintaining effective work and social
  1.  ;;        relationships
  1.  ;;    ___ Difficulty in adapting to stressful circumstances, including work or a
  1.  ;;        worklike setting
  1.  ;;    ___ Inability to establish and maintain effective relationships
  1.  ;;    ___ Suicidal ideation
  1.  ;;    ___ Obsessional rituals which interfere with routine activities
  1.  ;;    ___ Impaired impulse control, such as unprovoked irritability with periods
  1.  ;;        of violence
  1.  ;;    ___ Spatial disorientation
  1.  ;;    ___ Persistent delusions or hallucinations
  1.  ;;    ___ Grossly inappropriate behavior
  1.  ;;    ___ Persistent danger of hurting self or others
  1.  ;;    ___ Neglect of personal appearance and hygiene
  1.  ;;    ___ Intermittent inability to perform activities of daily living,
  1.  ;;        including maintenance of minimal personal hygiene
  1.  ;;    ___ Disorientation to time or place
  1.  ;;
  1.  ;; 6. Other symptoms
  1.  ;; Does the Veteran have any other symptoms attributable to PTSD (and other
  1.  ;; mental disorders) that are not listed above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe: ___________________________________________________________
  1.  ;;^TOF^
  1.  ;; 7. Competency
  1.  ;; Is the Veteran capable of managing his or her financial affairs?
  1.  ;; ___ Yes   ___ No
  1.  ;; If no, explain: _____________________________________________________________
  1.  ;;
  1.  ;; 8. Remarks, if any __________________________________________________________
  1.  ;;
  1.  ;; Psychiatrist/Psychologist signature & title: _______________________________
  1.  ;;
  1.  ;; Psychiatrist/Psychologist printed name: ____________________________________
  1.  ;;
  1.  ;; Date: ________________________   Phone: ____________________________________
  1.  ;;
  1.  ;; License #: ___________________   Fax: ______________________________________ 
  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.  ;;^END^
  1.  Q