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Routine: DVBCQPT6

DVBCQPT6.m

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DVBCQPT6 ;;ALB-CIOFO/SBW - PTSD QUESTIONNAIRE (v2) ; 14/JUNE/2011

 ;;2.7;AMIE;**171**;Apr 10, 1995;Build 2

 ;

TXT ;

 ;; c. If a diagnosis of TBI exists, is it possible to differentiate what portion

 ;; of the occupational and social impairment indicated above is caused by the TBI?

 ;; ___ Yes   ___ No  ___ No diagnosis of TBI

 ;; 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: _______________________________

 ;;

 ;;^TOF^

 ;;                                 SECTION II:

 ;;                                 -----------  

 ;;                              Clinical Findings:

 ;;                              ------------------

 ;;

 ;; 1. Evidence review

 ;; In order to provide an accurate medical opinion, the Veteran's claims folder

 ;; must be reviewed.

 ;; a. Records reviewed (check all that apply):

 ;; ___  Claims folder (C-file):

 ;;      ___ Yes

 ;;      ___ No

 ;;      If no, provide reason C-file was not reviewed: _________________________

 ;; ___ Other, please describe: _________________________________________________

 ;; ___ No records were reviewed

 ;;

 ;; b. Was pertinent information from collateral sources reviewed?

 ;; ___ Yes   ___ No

 ;; If yes, describe: ___________________________________________________________

 ;;

 ;; 2. History

 ;; a. Relevant Social/Marital/Family history (pre-military, military, and post-

 ;; military): __________________________________________________________________

 ;;

 ;; b. Relevant Occupational and Educational history (pre-military, military, and

 ;; post-military): _____________________________________________________________

 ;;

 ;; c. Relevant Mental Health history, to include prescribed medications and

 ;; family mental health (pre-military, military, and post-military: ____________

 ;; _____________________________________________________________________________

 ;;

 ;; d. Relevant Legal and Behavioral history (pre-military, military, and post-

 ;; military): __________________________________________________________________

 ;;

 ;; e. Relevant Substance abuse history (pre-military, military, and post-

 ;; military): __________________________________________________________________

 ;;

 ;; f. Sentinel Event(s) (other than stressors): ________________________________

 ;; _____________________________________________________________________________

 ;;

 ;; g. Other, if any: ___________________________________________________________

 ;;^TOF^

 ;; 3. Stressors

 ;; The stressful event can be due to combat, personal trauma, other life

 ;; threatening situations (non-combat related 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.

 ;;

 ;; Describe one or more specific stressor event (s) the Veteran considers

 ;; traumatic (may be pre-military, military, or post-military):

 ;;

 ;; a. Stressor #1: ___________________

 ;; 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: ___________________

 ;; 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: ___________________

 ;; 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 (list using the

 ;; above sequential format): ___________________________________________________ 

 ;;^TOF^

 ;; 4. PTSD Diagnostic Criteria

 ;; a. Please check criteria used for establishing the current PTSD diagnosis.

 ;; The diagnostic criteria for PTSD, referred to as Criteria A-F, are from the

 ;; Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).

 ;;

 ;; Criterion A: The Veteran has been exposed to a traumatic event where both of

 ;; the following were present:

 ;;    ___ The Veteran experienced, witnessed or was confronted with an event

 ;;        that involved actual or threatened death or serious injury, or a

 ;;        threat to the physical integrity of self or others.

 ;;    ___ The Veteran's response involved intense fear, helplessness or horror.

 ;;    ___ No exposure to a traumatic event.

 ;;

 ;; Criterion B: The traumatic event is persistently reexperienced in 1 or more

 ;; of the following ways:

 ;;    ___ Recurrent and distressing recollections of the event, including images,

 ;;        thoughts or perceptions

 ;;    ___ Recurrent distressing dreams of the event

 ;;    ___ Acting or feeling as if the traumatic event were recurring; this

 ;;        includes a sense of reliving the experience, illusions, hallucinations

 ;;        and dissociative flashback episodes, including those that occur on

 ;;        awakening or when intoxicated

 ;;    ___ Intense psychological distress at exposure to internal or external cues

 ;;        that symbolize or resemble an aspect of the traumatic event

 ;;    ___ Physiological reactivity on exposure to internal or external cues that

 ;;        symbolize or resemble an aspect of the traumatic event

 ;;    ___ The traumatic event is not persistently reexperienced

 ;;

 ;; Criterion C: Persistent avoidance of stimuli associated with the trauma and

 ;; numbing of general responsiveness (not present before the trauma), as

 ;; indicated by 3 or more of the following:

 ;;    ___ Efforts to avoid thoughts, feelings or conversations associated with

 ;;        the trauma

 ;;    ___ Efforts to avoid activities, places or people that arouse recollections

 ;;        of the trauma

 ;;    ___ Inability to recall an important aspect of the trauma

 ;;    ___ Markedly diminished interest or participation in significant activities

 ;;    ___ Feeling of detachment or estrangement from others

 ;;    ___ Restricted range of affect (e.g., unable to have loving feelings)

 ;;    ___ Sense of a foreshortened future (e.g., does not expect to have a career,

 ;;        marriage, children or a normal life span)

 ;;    ___ No persistent avoidance of stimuli associated with the trauma or numbing

 ;;        of general  responsiveness

 ;;^TOF^

 ;; Criterion D: Persistent symptoms of increased arousal, not present before the

 ;; trauma, as indicated by 2 or more of the following:

 ;;    ___ Difficulty falling or staying asleep

 ;;    ___ Irritability or outbursts of anger

 ;;    ___ Difficulty concentrating

 ;;    ___ Hypervigilance

 ;;    ___ Exaggerated startle response

 ;;    ___ No persistent symptoms of increased arousal

 ;;

 ;; Criterion E:

 ;;    ___ The duration of the symptoms described above in Criteria B, C and D

 ;;        is more than 1 month.

 ;;    ___ The duration of the symptoms described above in Criteria B, C and D

 ;;        is less than 1 month.

 ;;    ___ Veteran does not meet full criteria for PTSD

 ;;

 ;; Criterion F:

 ;;    ___ The PTSD symptoms described above cause clinically significant distress

 ;;        or impairment in social, occupational, or other important areas of

 ;;        functioning.

 ;;    ___ The PTSD symptoms described above do NOT cause clinically significant

 ;;        distress or impairment in social, occupational, or other important areas

 ;;        of functioning.

 ;;    ___ Veteran does not meet full criteria for PTSD

 ;;

 ;; b. Which stressor(s) contributed to the Veteran's PTSD diagnosis?:

 ;;    ___ Stressor #1

 ;;    ___ Stressor #2

 ;;    ___ Stressor #3

 ;;    ___ Other, please indicate stressor number (i.e. stressor #4, #5, etc.) as

 ;;        indicated above): ____________________________________________________

 ;;^TOF^

 ;; 5. Symptoms

 ;; For VA rating purposes, check all symptoms that apply to the Veteran's

 ;; diagnoses:

 ;;    ___ Depressed mood

 ;;    ___ Anxiety

 ;;    ___ Suspiciousness

 ;;    ___ Panic attacks that occur weekly or less often

 ;;    ___ Panic attacks more than once a week

 ;;    ___ Near-continuous panic or depression affecting the ability to function

 ;;        independently, appropriately and effectively

 ;;    ___ Chronic sleep impairment

 ;;    ___ Mild memory loss, such as forgetting names, directions or recent events

 ;;    ___ Impairment of short- and long-term memory, for example, retention of

 ;;        only highly learned material, while forgetting to complete tasks

 ;;    ___ Memory loss for names of close relatives, own occupation, or own name

 ;;    ___ Flattened affect

 ;;    ___ Circumstantial, circumlocutory or stereotyped speech

 ;;    ___ Speech intermittently illogical, obscure, or irrelevant

 ;;    ___ Difficulty in understanding complex commands

 ;;    ___ Impaired judgment

 ;;    ___ Impaired abstract thinking

 ;;    ___ Gross impairment in thought processes or communication

 ;;    ___ Disturbances of motivation and mood

 ;;    ___ Difficulty in establishing and maintaining effective work and social

 ;;        relationships

 ;;    ___ Difficulty in adapting to stressful circumstances, including work or a

 ;;        worklike setting

 ;;    ___ Inability to establish and maintain effective relationships

 ;;    ___ Suicidal ideation

 ;;    ___ Obsessional rituals which interfere with routine activities

 ;;    ___ Impaired impulse control, such as unprovoked irritability with periods

 ;;        of violence

 ;;    ___ Spatial disorientation

 ;;    ___ Persistent delusions or hallucinations

 ;;    ___ Grossly inappropriate behavior

 ;;    ___ Persistent danger of hurting self or others

 ;;    ___ Neglect of personal appearance and hygiene

 ;;    ___ Intermittent inability to perform activities of daily living,

 ;;        including maintenance of minimal personal hygiene

 ;;    ___ Disorientation to time or place

 ;;

 ;; 6. 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: ___________________________________________________________

 ;;^TOF^

 ;; 7. Competency

 ;; Is the Veteran capable of managing his or her financial affairs?

 ;; ___ Yes   ___ No

 ;; If no, explain: _____________________________________________________________

 ;;

 ;; 8. Remarks, if any __________________________________________________________

 ;;

 ;; Psychiatrist/Psychologist signature & title: _______________________________

 ;;

 ;; Psychiatrist/Psychologist printed name: ____________________________________

 ;;

 ;; Date: ________________________   Phone: ____________________________________

 ;;

 ;; License #: ___________________   Fax: ______________________________________ 

 ;;

 ;; 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