| RPT |
.|.|PTSD Status Form||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN: <.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.>
of War?| <*Answer_3950*>|17. Did the veteran ever observe others or participate him/herself in atrocities, such as torturing prisoners, mutilating enemy bodies, or harming civilians? If veteran
both observed and participated, select "Participated." | <*Answer_3951*>|18. Has the veteran ever been hospitalized for treatment of an emotional or substance use problem, including war stress
(PTSD)?| <*Answer_3952*>|19. Has the veteran ever received professional treatment as an outpatient for an emotional or substance use problem, including war stress (PTSD)?| <*Answer_3953*>|20.
During the past 30 days, has the veteran been taking a prescribed medication for a psychological/emotional problem?| <*Answer_3954*>|21. Does the veteran have any chronic, medical problems (e.g.,
diabetes, high blood pressure, epilepsy) which continue to interfere with his/her life?| <*Answer_3955*>|22. What is the highest level the veteran completed in school (e.g., completing high school
is 12, GED is 12)?| <*Answer_3959*>|23. Is the veteran working now?| <*Answer_3962*>|23A. If "No," what is the major reason?| <*Answer_3963*>|24. Has the veteran ever been incarcerated
(i.e., been in jail or prison) in his/her life?| <*Answer_3966*>|25. PTSD| <*Answer_3967*>|26. PTSS (subthreshold for PTSD)| <*Answer_3968*>|27. Alcohol Abuse/Dependence|
<*Answer_3972*>|28. Drug Abuse/Dependence| <*Answer_3973*>|29. Anxiety Disorder (other than PTSD)| <*Answer_3974*>|30. Affective Disorder (other than Bipolar Disorder)| <*Answer_3975*>|31.
Bipolar Disorder| <*Answer_3976*>|32. Schizophrenia| <*Answer_3977*>|33. Psychosis (other than Schizophrenia)| <*Answer_3978*>|34. Other Axis I| <*Answer_3979*>|35. Personality Disorder|
<*Answer_3980*>|36. What was the source of referral to your program?| <*Answer_3981*>|37. Has the veteran ever been treated before in a specialized PTSD program?| <*Answer_3982*>|38. Within
(<.Patient_Age.>)|Gender: <.Patient_Gender.>|||1. Clinician's name| <*Answer_3930*>|2. Data entered by| <*Answer_4185*>|3. Date of admission for treatment| <*Answer_3931*>|4. Date of
the past 30 days, has the veteran experienced trouble controlling violent behavior (e.g., hitting someone)?| <*Answer_3983*>|39. Has the staff of your program verified the veteran's war zone
service by reference to the DD 214 or similar military records?| <*Answer_3984*>|40. Is the veteran being evaluated for PTSD due to sexual trauma which occurred during active duty?|
<*Answer_3985*>|40A. Is the veteran being evaluated for PTSD due to sexual trauma which occurred before or after tour of active military duty?| <*Answer_3986*>|41. Is the veteran being evaluated
for PTSD due to noncombat nonsexual trauma which was incurred in the course of military duties?| <*Answer_3987*>|42. To what specialized program is this veteran being admitted?|
<*Answer_3989*>| $~
data-entry| <*Answer_4186*>|5. Marital status| <*Answer_3938*>|6. Race/Ethnic ancestry| <*Answer_3939*>|7. For PTSD (Pre-1980: PTSD often diagnosed as Psychoneurosis)| <*Answer_3940*>|8.
For psychiatric, other than PTSD| <*Answer_3941*>|9. For medical, non-psychiatric| <*Answer_3942*>|10. For psychiatric (including PTSD)| <*Answer_5110*>|11. For physical|
<*Answer_5111*>|12. Veteran's living arrangement at the time of admission to this program.| <*Answer_3946*>|12A. Is the veteran currently on an active tour of duty in the armed forces?|
<*Answer_5094*>|12B. Is the veteran currently in the Reserves?| <*Answer_5095*>|12C. Is the veteran currently in the National Guard?| <*Answer_5100*>|13. Period of service. (Check all that
apply)| <*Answer_5097*>|Afghanistan| <*Answer_4004*>|Iraq| <*Answer_4005*>|13B. Did the veteran ever serve in the United States military in a peace-keeping operation (such as in Lebanon,
Somalia, Bosnia, Kosovo)?| <*Answer_4006*>|14. Did the veteran ever serve in a war zone?| <*Answer_3948*>|14A. In what capacity did the veteran most recently serve in a war zone? (Check one
below)| <*Answer_5098*>|15. Did the veteran receive friendly or hostile incoming fire from small arms, artillery, rockets, mortars or bombs?| <*Answer_3949*>|16. Was the veteran ever a Prisoner
|
