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1DVBCWPE1 ;ESW/ PTSD WKS TEXT - 1 ; 9 Oct 2000
2 ;;2.7;AMIE;**34**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;
7 ;;A. Review of Medical Records
8 ;;
9 ;;B. Medical History since last exam:
10 ;; Comments on:
11 ;;
12 ;; 1. Hospitalizations and outpatient care from the time between last
13 ;; rating examination to the present, UNLESS the purpose of this
14 ;; examination is to ESTABLISH service connection, then the complete
15 ;; medical history since discharge from military service is required.
16 ;; 2. Frequency, severity and duration of psychiatric symptoms.
17 ;; 3. Length of remissions from psychiatric symptoms, to include capacity
18 ;; for adjustment during periods of remissions.
19 ;; 4. Treatments including statement on effectiveness and side effects
20 ;; experienced.
21 ;; 5. SUBJECTIVE COMPLAINTS: Describe fully.
22 ;;
23 ;;C. Psychosocial Adjustment since the last exam
24 ;;
25 ;; * legal history (DWIs, arrests, time spent in jail)
26 ;; * educational accomplishment
27 ;; * extent of time list from work over the past 12 month period and social
28 ;; impairment. If employed, identify current occupation and length of time
29 ;; at this job.
30 ;; If unemployed, note in COMPLAINTS whether veteran contends it is due to
31 ;; the effects of a mental disorder. Further indicate following DIAGNOSIS
32 ;; what factors, and objective findings support or rebut that contention.
33 ;; * marital and family relationships ( including quality of relationships with
34 ;; spouse and children)
35 ;; * degree and quality of social relationships
36 ;; * activities and leisure pursuits
37 ;; * problematic substance abuse
38 ;; * significant medical disorders (resulting pain or disability; current
39 ;; medications)
40 ;; * history of violence/assaultiveness
41 ;; * history of suicide attempts
42 ;; * summary statement of current psychosocial functional status (performance
43 ;; in employment or schooling, routine responsibilities of self care,
44 ;; family role functioning, physical health, social/interpersonal
45 ;; relationship, recreation/leisure pursuits)
46 ;;TOF
47 ;;D. Mental Status Examination
48 ;;
49 ;; Conduct a BRIEF mental status examinaton aimed at screening for DSM-IV mental
50 ;; disorders. Describe and fully explain the existence, frequency and extent of
51 ;; the following signs and symptoms, or any others present, and relate how they
52 ;; interfere with employment and social functioning:
53 ;;
54 ;; * Impairment of thought process or communication.
55 ;; * Delusions, hallucinations and their persistence.
56 ;; * Eye Contact, interaction in session, and inappropriate behavior cited
57 ;; with examples.
58 ;; * Suicidal or homicidal thoughts, ideations or plans or intent.
59 ;; * Ability to maintain minimal personal hygiene and other basic activities
60 ;; of daily living.
61 ;; * Orientation to person, place, and time.
62 ;; * Memory loss, or impairment (both short and long-term).
63 ;; * Obsessive or ritualistic behavior which interferes with routine activities
64 ;; and describe any found.
65 ;; * Rate and flow of speech and note any irrelevant, illogical, or obscure
66 ;; speech patterns and whether constant or intermittent.
67 ;; * Panic attacks noting the severity, duration, frequency, and effect on
68 ;; independent functioning and whether clinically observed or good evidence
69 ;; of prior clinical or equivalent observation is shown.
70 ;; * Depression, depressed mood or anxiety.
71 ;; * Impaired impulse control and its effect on motivation or mood.
72 ;; * Sleep impairment and describe extent it interferes with daytime activities.
73 ;; * Other disorders or symptoms and the extent they interfere with activities,
74 ;; particularly:
75 ;;
76 ;; - mood disorders ( especially major depression and dysthymia)
77 ;; - substance use disorders (especially alcohol use disorders)
78 ;; - anxiety disorders (especially panic disorder, obsessive-compulsive
79 ;; disorder, generalized anxiety disorder)
80 ;; - somatoform disorders
81 ;; - personality disorders (especially antisocial personality disorder
82 ;; and borderline personality disorder)
83 ;;
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