DVBCWPF3 ;ALB/RLC - INITIAL EVAL PTSD WORKSHEET TEXT ; 05/18/2006 11:00am
;;2.7;AMIE;**87**;Apr 10, 1995;Build 6
;Per VHA Directive 10-92-142, this routine should not be modified
;
TXT ;
;;
;;N. Effects of PTSD on Occupational and Social Functioning
;;
;;Evaluation of PTSD is based on its effects on occupational and social
;;functioning. Select the appropriate assessment of the veteran from the
;;choices below:
;;
;; - Total occupational and social impairment due to PTSD signs and
;; symptoms.
;;
;; Provide examples and pertinent symptoms, including those
;; already reported.
;;
;; OR
;;
;; - PTSD signs and symptoms result in deficiencies in most of the
;; following areas:
;; work, school, family relations, judgement, thinking, and mood.
;;
;; Provide examples and pertinent symptoms, including those already
;; reported for each affected area.
;;
;; OR
;;
;; - There is reduced reliability and productivity due to PTSD signs and
;; symptoms.
;;
;; Provide examples and pertinent symptoms, including those already
;; reported.
;;TOF
;; OR
;;
;; - There is occasional decrease in work efficiency or there are
;; intermittent periods of inability to perform occupational tasks due
;; to signs and symptoms, but generally satisfactory functioning
;; (routine behavior, self-care, and conversation normal).
;;
;; Provide examples and pertinent symptoms, including those already
;; reported.
;;
;; OR
;;
;; - There are PTSD signs and symptoms that are transient or mild and
;; decrease work efficiency and ability to perform occupational tasks
;; only during periods of significant stress.
;;
;; Provide examples and pertinent symptoms, including those already
;; reported.
;;
;; OR
;;
;; - PTSD symptoms require continuous medication.
;;
;; OR
;;
;; - Select all that apply:
;; - PTSD symptoms are not severe enough to require continuous medication.`
;; - PTSD symptoms are not severe enough to interfere with occupational
;; and social functioning.
;;
;;
;; Include your name; your credentials (i.e., board certified psychiatrist,
;; a licensed psychologist, a psychiatry resident or a psychology intern);
;; and circumstances under which you performed the examination, if applicable
;; (i.e., under the close supervision of an attending psychiatrist or
;; psychologist); include name of supervising psychiatrist or psychologist.
;;
;;
;;Signature of Examiner: Date:
;;
;;Signature of Supervising
;;psychiatrist or psychologist: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWPF3 3020 printed Sep 23, 2025@19:29:29 Page 2
DVBCWPF3 ;ALB/RLC - INITIAL EVAL PTSD WORKSHEET TEXT ; 05/18/2006 11:00am
+1 ;;2.7;AMIE;**87**;Apr 10, 1995;Build 6
+2 ;Per VHA Directive 10-92-142, this routine should not be modified
+3 ;
TXT ;
+1 ;;
+2 ;;N. Effects of PTSD on Occupational and Social Functioning
+3 ;;
+4 ;;Evaluation of PTSD is based on its effects on occupational and social
+5 ;;functioning. Select the appropriate assessment of the veteran from the
+6 ;;choices below:
+7 ;;
+8 ;; - Total occupational and social impairment due to PTSD signs and
+9 ;; symptoms.
+10 ;;
+11 ;; Provide examples and pertinent symptoms, including those
+12 ;; already reported.
+13 ;;
+14 ;; OR
+15 ;;
+16 ;; - PTSD signs and symptoms result in deficiencies in most of the
+17 ;; following areas:
+18 ;; work, school, family relations, judgement, thinking, and mood.
+19 ;;
+20 ;; Provide examples and pertinent symptoms, including those already
+21 ;; reported for each affected area.
+22 ;;
+23 ;; OR
+24 ;;
+25 ;; - There is reduced reliability and productivity due to PTSD signs and
+26 ;; symptoms.
+27 ;;
+28 ;; Provide examples and pertinent symptoms, including those already
+29 ;; reported.
+30 ;;TOF
+31 ;; OR
+32 ;;
+33 ;; - There is occasional decrease in work efficiency or there are
+34 ;; intermittent periods of inability to perform occupational tasks due
+35 ;; to signs and symptoms, but generally satisfactory functioning
+36 ;; (routine behavior, self-care, and conversation normal).
+37 ;;
+38 ;; Provide examples and pertinent symptoms, including those already
+39 ;; reported.
+40 ;;
+41 ;; OR
+42 ;;
+43 ;; - There are PTSD signs and symptoms that are transient or mild and
+44 ;; decrease work efficiency and ability to perform occupational tasks
+45 ;; only during periods of significant stress.
+46 ;;
+47 ;; Provide examples and pertinent symptoms, including those already
+48 ;; reported.
+49 ;;
+50 ;; OR
+51 ;;
+52 ;; - PTSD symptoms require continuous medication.
+53 ;;
+54 ;; OR
+55 ;;
+56 ;; - Select all that apply:
+57 ;; - PTSD symptoms are not severe enough to require continuous medication.`
+58 ;; - PTSD symptoms are not severe enough to interfere with occupational
+59 ;; and social functioning.
+60 ;;
+61 ;;
+62 ;; Include your name; your credentials (i.e., board certified psychiatrist,
+63 ;; a licensed psychologist, a psychiatry resident or a psychology intern);
+64 ;; and circumstances under which you performed the examination, if applicable
+65 ;; (i.e., under the close supervision of an attending psychiatrist or
+66 ;; psychologist); include name of supervising psychiatrist or psychologist.
+67 ;;
+68 ;;
+69 ;;Signature of Examiner: Date:
+70 ;;
+71 ;;Signature of Supervising
+72 ;;psychiatrist or psychologist: Date:
+73 ;;END
