| RPT |
.| .| VETERANS AFFAIRS MILITARY STRESS TREATMENT ASSESSMENT FORM A| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>|
can range from 0% to 100%)| <*Answer_4729*>| 14. Are you currently applying for or planning to apply for service connection for PTSD or for an increase in percent service disability for PTSD?|
<*Answer_4730*>| 15. Are you currently taking any medications for PTSD or for other emotional problems that have been prescribed for you by a psychiatrist or other physician?| <*Answer_4731*>|
16a. Outpatient PTSD treatment from any VA medical center| <*Answer_4732*>| 16b. Outpatient PTSD treatment from a Vet Center| <*Answer_4733*>| 16c. Outpatient PTSD treatment from any non-VA
program| <*Answer_4734*>| 16d. Outpatient treatment of substance use problems from a VA addictions program| <*Answer_4735*>| 16e. Outpatient treatment of substance use problems from a non-VA
addictions program| <*Answer_4736*>| 16f. Self-help groups for substance use problems (such as AA or NA)| <*Answer_4737*>| 16g. Individual meetings with a chaplain in the VA while you were an
outpatient| <*Answer_4738*>| 16h. Individual meetings with a chaplain in the VA while you were an inpatient| <*Answer_4739*>| 16i. Individual meetings with a member of the clergy outside of
the VA| <*Answer_4740*>| 16j. Emergency room visits at any VA or non-VA medical center for PTSD-related problems| <*Answer_4741*>| 16k. Inpatient or residential admission for PTSD at a VA
Medical Center for any PTSD-related problem (NOT substance use problems)| <*Answer_4742*>| 16l. Inpatient or residential admission at a VA Medical Center for substance use problems|
<*Answer_4743*>| 16m. Inpatient or residential admission at a VA Medical Center for a suicide attempt or concern about a suicide attempt| <*Answer_4744*>| 16n. Inpatient or residential admission
at a VA Medical Center for an emotional problem other than PTSD, substance use or suicide attempt| <*Answer_4745*>| 17. I have nightmares of experiences in the military that really happened.|
SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | Questions and Answers| | 1. Type of Specialized PTSD Program:| <*Answer_4715*>| 2. Admission
<*Answer_4746*>| 18. Lately, I have felt like killing myself.| <*Answer_4747*>| 19. I fall asleep, stay asleep and only awaken when it's time to get up.| <*Answer_4748*>| 20. My dreams at
night are so real that I waken in a cold sweat and force myself to stay awake.| <*Answer_4749*>| 21. I feel like I cannot go on.| <*Answer_4750*>| 22. I do not laugh or cry at the same things
other people do.| <*Answer_4751*>| 23. I enjoy the company of others.| <*Answer_4752*>| 24. I wonder why I am still alive when others died in the military.| <*Answer_4753*>| 25.
Unexpected noises make me jump.| <*Answer_4754*>| 26. There are times when I used alcohol (or other drugs) to help me sleep or make me forget about things that happened while I was in the
service.| <*Answer_4755*>| 27. I lose my cool and explode over minor everyday things.| <*Answer_4756*>| 28. I have a hard time expressing my feelings, even to the people I care about.|
<*Answer_4757*>| 29. When I think of some of the things that I did in the military, I wish I were dead.| <*Answer_4758*>| 30a. Repeated, disturbing memories, thoughts, or images of a stressful
military experience?| <*Answer_4759*>| 30b. Repeated, disturbing dreams of a stressful military experience?| <*Answer_4760*>| 30c. Suddenly acting or feeling as if a stressful military
experience were happening again (as if you were reliving it)?| <*Answer_4761*>| 30d. Feeling very upset when something reminded you of a stressful military experience?| <*Answer_4762*>| 30e.
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful military experience?| <*Answer_4763*>| 30f. Avoiding thinking about or
talking about a stressful military experience or avoiding having feelings related to it?| <*Answer_4764*>| 30g. Avoiding activities or situations because they reminded you of a stressful military
Date to this Program (mm/dd/yyyy):| <*Answer_4716*>| 3. Date of this Report (mm/dd/yyyy):| <*Answer_4717*>| 4. What is the highest year of education that you completed? (For example, "12"
experience?| <*Answer_4765*>| 30h. Trouble remembering important parts of a stressful military experience?| <*Answer_4766*>| 30i. Loss of interest in activities that you used to enjoy?|
<*Answer_4767*>| 30j. Feeling distant or cut off from other people?| <*Answer_4768*>| 30k. Feeling emotionally numb or being unable to have loving feelings for those close to you?|
<*Answer_4769*>| 30l. Feeling as if your future somehow will be cut short?| <*Answer_4770*>| 30m. Trouble falling or staying asleep?| <*Answer_4771*>| 30n. Feeling irritable or having angry
outbursts?| <*Answer_4772*>| 30o. Having difficulty concentrating?| <*Answer_4773*>| 30p. Being "superalert" or watchful or on guard?| <*Answer_4774*>| 30q. Feeling jumpy or easily
startled?| <*Answer_4775*>| 31. How well are you able to cope with military stress reactions so that they don't interfere too greatly with your life?| <*Answer_4776*>| 32a. Little interest or
pleasure in doing things| <*Answer_4777*>| 32b. Feeling down, depressed, or hopeless.| <*Answer_4778*>| 32c. Trouble falling or staying asleep, or sleeping too much.| <*Answer_4779*>|
32d. Feeling tired or having little energy.| <*Answer_4780*>| 32e. Poor appetite or overeating.| <*Answer_4781*>| 32f. Feeling bad about yourself-or that you are a failure or have let
yourself or your family down.| <*Answer_4782*>| 32g. Trouble concentrating on things, such as reading the newspaper or watching television.| <*Answer_4783*>| 32h. Moving or speaking so slowly
that other people could have noticed? Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual.| <*Answer_4784*>| 32i. Thoughts that you would be
better off dead or hurting yourself in some way.| <*Answer_4785*>| 33. During the past month, my desire to make an active suicide attempt.| <*Answer_4786*>| 34. During the past month, I
for high school graduate or GED, "16" for college bachelor's degree, "20" for advanced professional degree.)| <*Answer_4718*>| 5. What is your race or ethnic ancestry?| <*Answer_4719*>| 6.
thought of suicide.| <*Answer_4787*>| 35. During the past month, when I thought of suicide.| <*Answer_4788*>| 36. Have you attempted suicide at any time in the last 4 months?|
<*Answer_4789*>| 37. Do you have immediate access to loaded firearms that don't have trigger locks or other safety features (for example, by the bed, in the car, in the home)?| <*Answer_4790*>|
38. During the past month on average, how many hours of actual sleep did you get per night? (This may be different than the number of hours you spent in bed.) Round to the nearest whole hour.|
<*Answer_4791*>| 39. During the past month, how would you rate your sleep quality overall?| <*Answer_4792*>| 40. Did your use of alcohol in the past 4 months lead to any problems in your life,
such as in meeting your responsibilities or in your relationships with other people?| <*Answer_4793*>| 41. Did you have to demonstrate to the staff of this program that you could be sober for a
few weeks before they would begin treating you?| <*Answer_4794*>| 42. How many days in the 4 months prior to beginning this program did you drink alcohol at all?| <*Answer_4795*>| 42a. How
many days in the 4 months prior to beginning this program did you drink alcohol to the point where you felt drunk or intoxicated or had 3 or more drinks in one sitting?| <*Answer_4796*>| 43a. I
have been unhappy because of my drinking.| <*Answer_4797*>| 43b. I have taken foolish risks when I have been drinking.| <*Answer_4798*>| 43c. My physical health has been harmed by my
drinking.| <*Answer_4799*>| 43d. My drinking has gotten in the way of my growth as a person.| <*Answer_4800*>| 43e. My drinking has damaged my social life, popularity, or reputation.|
<*Answer_4801*>| 43f. I have spent too much or lost a lot of money because of my drinking.| <*Answer_4802*>| 43g. I have had an automobile accident or injured myself while drinking or while
Did you ever serve in a war zone?| <*Answer_4720*>| 6a. Check all war zones that apply:| <*Answer_4721*>| 7. Did you ever receive friendly or hostile fire from small arms, artillery, rockets,
intoxicated.| <*Answer_4803*>| 44. Did your use of drugs, such as marijuana, heroin or cocaine, in the past 4 months lead to any problems in your life, such as in meeting your responsibilities or
in your relationships with other people? | <*Answer_4804*>| 45. Did you have to demonstrate to the staff of this program that you could be clean (that is, drug free) for a few weeks before
they would begin treating you?| <*Answer_4805*>| 46. How many days in the past 4 months prior to beginning this program did you use drugs at all?| <*Answer_4806*>| 47a. Because of my drug
use, I have not eaten properly.| <*Answer_4807*>| 47b. I have failed to do what is expected of me because of my drug use.| <*Answer_4808*>| 47c. I have felt guilty or ashamed because of my
drug use.| <*Answer_4809*>| 47d. When using drugs, I have done impulsive things that I regretted later.| <*Answer_4810*>| 47e. I have had money problems because of my drug use.|
<*Answer_4811*>| 47f. My family has been hurt by my drug use.| <*Answer_4812*>| 47g. A friendship or close relationship has been damaged by my drug use.| <*Answer_4813*>| 48. Overall, how
would you rate your health during the past 4 weeks?| <*Answer_4814*>| 49. During the past 4 weeks, how much did physical health problems limit your usual physical activities (such as walking or
climbing stairs)?| <*Answer_4815*>| 50. During the past 4 weeks, how much difficulty did you have doing your daily work, both at home and away from home, because of your physical health?|
<*Answer_4816*>| 51. How much bodily pain have you had during the past 4 weeks?| <*Answer_4817*>| 52. During the past 4 weeks, how much energy did you have?| <*Answer_4818*>| 53. During the
past 4 weeks, how much did your physical health or emotional problems limit your usual social activities with family or friends?| <*Answer_4819*>| 54. During the past 4 weeks, how much have you
mortars or bombs?| <*Answer_4722*>| 8. Were you ever a prisoner of war?| <*Answer_4723*>| 9. Did you ever observe others or participate yourself in atrocities, such as torturing prisoners,
been bothered by emotional problems (such as feeling anxious, depressed, or irritable)?| <*Answer_4820*>| 55. During the past 4 weeks, how much did personal or emotional problems keep you from
doing your usual work, school or other daily activities?| <*Answer_4821*>| 56. How many days have you experienced medical problems in the past 30 days? (Include both major and minor ailments
except temporary alcohol or drug problems. If no problems, enter "0"| <*Answer_4822*>| 57. How troubled or bothered have you been by these medical problems in the past 30 days?|
<*Answer_4823*>| 58. How important to you now is additional treatment beyond what you have been receiving all along for these medical problems?| <*Answer_4824*>| 59. On average, about how many
cigarettes a day do you smoke? (1 pack is 20 cigarettes.)| <*Answer_4825*>| 60. Over the past month, how often have you engaged in regular activities (for example, brisk walking, jogging,
bicycling, etc.) long enough to work up a sweat?| <*Answer_4826*>| 61. 5ave you used any health care services for your physical health within the last year?| <*Answer_4827*>| 62. I find
strength and comfort in my religion.| <*Answer_4828*>| 63. My religion provides me with satisfying answers to questions about the meaning or purpose of life.| <*Answer_4829*>| 64. My whole
approach to life is based on my religion.| <*Answer_4830*>| 65. What religion offers me most is comfort in times of trouble and sorrow.| <*Answer_4831*>| 66. I go to church mainly because I
enjoy seeing people I know there.| <*Answer_4832*>| 67. I feel God's presence.| <*Answer_4833*>| 68. I feel deep inner peace or harmony.| <*Answer_4834*>| 69. I feel God's love for me,
directly or through others.| <*Answer_4835*>| 70. I am spiritually touched by the beauty of creation.| <*Answer_4836*>| 71. How often do you attend religious services?| <*Answer_4837*>|
mutilating enemy bodies, or harming civilians?| <*Answer_4724*>| 10. Were you ever sexually assaulted while you were in the military?| <*Answer_4725*>| 11. Were you ever threatened with
72. How often do you pray or meditate privately in places other than at a house of worship?| <*Answer_4838*>| 73. What is your employment status?| <*Answer_4839*>| 74. How many days did you
work for pay during the past 30 days?| <*Answer_4840*>| 75. During the past 4 months, how often have you had friends or relatives over to your home?| <*Answer_4841*>| 76. About how often have
you visited with friends or relatives at their homes during the past 4 months?| <*Answer_4842*>| 77. During the past 4 months, about how often did you go out with friends or relatives (for
example, meet for coffee, go to a movie, bowl, go to church)?| <*Answer_4843*>| 78. About how often did you have telephone, mail, or computer contact with friends or relatives during the past 4
months?| <*Answer_4844*>| 79. Did you do any of these during the last 4 months? (Check all that apply)| <*Answer_4845*>| 80. Got out of the house...| <*Answer_4846*>| 81. Did an activity
for pleasure or fun (for example, going to a movie, going fishing, playing chess)...| <*Answer_4847*>| 82. Did chores out in the community (for example, shopping, going to bank)...|
<*Answer_4848*>| 83a. Your life as a whole; that is, your health, your relationships with other people, and your recreational activities overall?| <*Answer_4849*>| 83b. The living arrangements
where you live?| <*Answer_4850*>| 83c. The way you spend your free time?| <*Answer_4851*>| 83d. The amount of time you spend with other people?| <*Answer_4852*>| 83e. The amount of fun
you have?| <*Answer_4853*>| 83f. The way things are in general between you and your family?| <*Answer_4854*>| 83g. The amount of friendship in your life?| <*Answer_4855*>| 83h. How
comfortable and well-off you are financially?| <*Answer_4856*>| 83i. Your physical condition?| <*Answer_4857*>| 83j. Your emotional well-being?| <*Answer_4858*>| 84. How easy or difficult
sexual assault in the military although you were never actually assaulted?| <*Answer_4726*>| 12. Were you ever sexually harassed in the military, although you were never sexually assaulted or
do you expect it to be to open up about yourself in treatment?| <*Answer_4859*>| 85. How effective do you think your care is likely to be in helping you achieve your goals for entering
treatment?| <*Answer_4860*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be
verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~
threatened with assault?| <*Answer_4727*>| 13. Have you been certified by the VA as service connected for PTSD?| <*Answer_4728*>| 13a. What is your disability percentage? (Percent disability
|
