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1DVBCWPD4 ;BP-CIOFO/MM - PTSD WORKSHEET TEXT ;3/27/2002
2 ;;2.7;AMIE;**43**;Apr 10, 1995
3 ;
4TXT ;
5 ;;
6 ;;A. Identifying Information
7 ;;
8 ;; - age
9 ;; - ethnic background
10 ;; - era of military service
11 ;; - reason for referral (original exam to establish PTSD diagnosis and
12 ;; related psychosocial impairment; re-evaluation of status of existing
13 ;; service-connected PTSD condition)
14 ;;
15 ;;B. Sources of Information
16 ;;
17 ;; * records reviewed (C-file, DD-214, medical records, other documentation)
18 ;; * review of social-industrial survey completed by social worker
19 ;; * statements from collaterals
20 ;; * administration of psychometric tests and questionnaires (identify here)
21 ;;
22 ;;C. Review of Medical Records:
23 ;;1. Past Medical History:
24 ;;
25 ;; a. Previous hospitalizations and outpatient care.
26 ;; b. Complete medical history is required, including history since discharge
27 ;; from military service.
28 ;; c. Review of Claims Folder is required on initial exams to establish or
29 ;; rule out the diagnosis.
30 ;;
31 ;;2. Present Medical History - over the past one year.
32 ;;
33 ;; a. Frequency, severity and duration of medical and psychiatric symptoms.
34 ;; b. Length of remissions, to include capacity for adjustment during periods
35 ;; of remissions.
36 ;;
37 ;;D. Examination (Objective Findings):
38 ;; Address each of the following and fully describe:
39 ;;
40 ;; History (Subjective Complaints):
41 ;; Comment on:
42 ;;
43 ;; Preliminary History (refer to social-industrial survey if completed)
44 ;;
45 ;; * describe family structure and environment where raised (identify
46 ;; constellation of family members and quality of relationships)
47 ;;TOF
48 ;; * quality of peer relationships and social adjustment (e.g., activities,
49 ;; achievements, athletic and/or extracurricular involvements, sexual
50 ;; involvement, etc.)
51 ;; * education obtained and performance in school
52 ;; * employment
53 ;; * legal infractions
54 ;; * delinquency or behavior conduct disturbances
55 ;; * substance use patterns
56 ;; * significant medical problems and treatments obtained
57 ;; * family psychiatric history
58 ;; * exposure to traumatic stressors (see CAPS trauma assessment checklist)
59 ;; * summary assessment of psychosocial adjustment and progression through
60 ;; developmental milestones (performance in employment or schooling,
61 ;; routine responsibilities of self-care, family role functioning,
62 ;; physical health, social/interpersonal relationship, recreation/leisure
63 ;; pursuits).
64 ;;
65 ;; Military History
66 ;;
67 ;; * branch of service (enlisted or drafted)
68 ;; * dates of service
69 ;; * dates and location of war zone duty and number of months stationed
70 ;; in war zone
71 ;; * Military Occupational Specialty (describe nature and duration of job(s)
72 ;; in war zone
73 ;; * highest rank obtained during service (rank at discharge if different)
74 ;; * type of discharge from military
75 ;; * describe routine combat stressors veterans was exposed to
76 ;; (refer to Combat Scale)
77 ;; * combat wounds sustained (describe)
78 ;; * CLEARLY DESCRIBE SPECIFIC STRESSOR EVENT(S) VETERAN CONSIDERED
79 ;; PARTICULARLY TRAUMATIC.
80 ;; Clearly describe the stressor. Particularly if the stressor is a type
81 ;; of personal assault, including sexual assault, provide information,
82 ;; with examples, if possible.
83 ;; * indicate overall level of traumatic stress exposure
84 ;; (high, moderate, low) based on frequency and severity of incident
85 ;; exposure
86 ;; * citations or medals received
87 ;; * disciplinary infractions or other adjustment problems during military
88 ;;
89 ;;NOTE: Service connection for post-traumatic stress disorder (PTSD) requires
90 ;;medical evidence establishing a diagnosis of the condition that conforms
91 ;;to the diagnostic criteria of DSM-IV, credible supporting evidence that
92 ;;the claimed in-service stressor actually occurred, and a link, established by
93 ;;medical evidence, between current symptomatology and the claimed in-service
94 ;;stressor. It is the responsibility of the examiner to indicate the traumatic
95 ;;stressor leading to PTSD, if he or she makes the diagnosis of PTSD.
96 ;; Crucial in this description are specific details of the stressor, with names,
97 ;; dates, and places linked to the stressor, so that the rating specialist can
98 ;; confirm that the cited stressor occurred during active duty.
99 ;;
100 ;;A diagnosis of PTSD cannot be adequately documented or ruled out without
101 ;;obtaining a detailed military history and reviewing the claims folder.
102 ;;This means that initial review of the folder prior to examination, the history
103 ;;and examination itself, and the dictation for an examination initially
104 ;;establishing PTSD will often require more time than for examinations of other
105 ;;disorders. Ninety minutes to two hours on an initial exam is normal.
106 ;;
107 ;; Post-Military Trauma History (refer to social-industrial survey if completed)
108 ;;
109 ;; * describe post-military traumatic events (see CAPS trauma assessment
110 ;; checklist)
111 ;; * describe psychosocial consequences of post-military trauma exposure(s)
112 ;; (treatment received, disruption to work, adverse health consequences)
113 ;;
114 ;; Post-Military Psychosocial Adjustment (refer to social-industrial survey
115 ;; if completed)
116 ;;
117 ;; * legal history (DWIs, arrests, time spent in jail)
118 ;; * educational accomplishment
119 ;; * employment history (describe periods of employment and reasons)
120 ;; * marital and family relationships (including quality of relationships with
121 ;; children)
122 ;; * degree and quality of social relationships
123 ;; * activities and leisure pursuits
124 ;; * problematic substance abuse (lifetime and current)
125 ;; * significant medical disorders (resulting pain or disability; current
126 ;; medications)
127 ;; * treatment history for significant medical conditions, including
128 ;; hospitalizations
129 ;; * history of inpatient and/or outpatient psychiatric care (dates and
130 ;; conditions treated)
131 ;; * history of assaultiveness
132 ;; * history of suicide attempts
133 ;; * summary statement of current psychosocial functional status (performance
134 ;; in employment or schooling, routine responsibilities of self care,
135 ;; family role functioning, physical health, social/interpersonal
136 ;; relationships, recreation/leisure pursuits)
137 ;;
138 ;;E. Mental Status Examination
139 ;;
140 ;; Conduct a BRIEF mental status examination aimed at screening for DSM-IV
141 ;; mental disorders. Describe and fully explain the existence, frequency and
142 ;; extent of the following signs and symptoms, or any others present, and
143 ;; relate how they interfere with employment and social functioning:
144 ;;
145 ;; * Impairment of thought process or communication.
146 ;; * Delusions, hallucinations and their persistence.
147 ;; * Eye Contact, interaction in session, and inappropriate behavior cited
148 ;; with examples.
149 ;; * Suicidal or homicidal thoughts, ideations or plans or intent.
150 ;; * Ability to maintain minimal personal hygiene and other basic activities
151 ;; of daily living.
152 ;; * Orientation to person, place, and time.
153 ;; * Memory loss, or impairment (both short and long-term).
154 ;; * Obsessive or ritualistic behavior which interferes with routine activities
155 ;; and describe any found.
156 ;; * Rate and flow of speech and note any irrelevant, illogical, or obscure
157 ;; speech patterns and whether constant or intermittent.
158 ;; * Panic attacks noting the severity, duration, frequency, and effect on
159 ;; independent functioning and whether clinically observed or good evidence
160 ;; of prior clinical or equivalent observation is shown.
161 ;; * Depression, depressed mood or anxiety.
162 ;; * Impaired impulse control and its effect on motivation or mood.
163 ;; * Sleep impairment and describe extent it interferes with daytime activities.
164 ;; * Other disorders or symptoms and the extent they interfere with activities,
165 ;; particularly:
166 ;;
167 ;; - mood disorders (especially major depression and dysthymia)
168 ;; - substance use disorders (especially alcohol use disorders)
169 ;; - anxiety disorders (especially panic disorder, obsessive-compulsive
170 ;; disorder, generalized anxiety disorder)
171 ;; - somatoform disorder
172 ;; - personality disorders (especially antisocial personality disorder
173 ;; and borderline personality disorder)
174 ;;
175 ;;Specify onset and duration of symptoms as acute, chronic, or with delayed onset.
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