| 1 | DVBCWPG3 ;ALB/RLC - REVIEW EXAM PTSD WORKSHEET TEXT ; 05/18/2006 12:00pm
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| 2 |  ;;2.7;AMIE;**87**;Apr 10, 1995;Build 6
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| 3 |  ;Per VHA Directive 10-92-142, this routine should not be modified
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| 4 |  ;
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| 5 | TXT ;
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| 6 |  ;;
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| 7 |  ;;M.  Effects of PTSD on Occupational and Social Functioning
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| 8 |  ;;
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| 9 |  ;;Evaluation of PTSD is based on its effects on occupational and social
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| 10 |  ;;functioning.  Select the appropriate assessment of the veteran from the
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| 11 |  ;;choices below:
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| 12 |  ;;
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| 13 |  ;;   - Total occupational and social impairment due to PTSD signs and symptoms.
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| 14 |  ;;
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| 15 |  ;;     Provide examples and pertinent symptoms, including those already reported.
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| 16 |  ;;
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| 17 |  ;;                           OR
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| 18 |  ;;
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| 19 |  ;;   - PTSD signs and symptoms result in deficiencies in most of the following
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| 20 |  ;;     areas:
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| 21 |  ;;     work, school, family relations, judgment, thinking, and mood.
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| 22 |  ;;
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| 23 |  ;;     Provide examples and pertinent symptoms, including those already 
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| 24 |  ;;     reported for each affected area.
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| 25 |  ;;TOF
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| 26 |  ;;                           OR
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| 27 |  ;;
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| 28 |  ;;   - There is reduced reliability and productivity due to PTSD signs and
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| 29 |  ;;     symptoms.
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| 30 |  ;;
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| 31 |  ;;     Provide examples and pertinent symptoms, including those already reported.
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| 32 |  ;;
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| 33 |  ;;                           OR
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| 34 |  ;;
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| 35 |  ;;   - There is occasional decrease in work efficiency or there are intermittent
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| 36 |  ;;     periods of inability to perform occupational tasks due to signs and
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| 37 |  ;;     symptoms, but generally satisfactory functioning (routine behavior,
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| 38 |  ;;     self-care, and conversation normal).
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| 39 |  ;;
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| 40 |  ;;     Provide examples and pertinent symptoms, including those already reported.
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| 41 |  ;;
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| 42 |  ;;                           OR
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| 43 |  ;;
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| 44 |  ;;   - There are PTSD signs and symptoms that are transient or mild and
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| 45 |  ;;     decrease work efficiency and ability to perform occupational tasks
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| 46 |  ;;     only during periods of significant stress.
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| 47 |  ;;
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| 48 |  ;;     Provide examples and pertinent symptoms, including those already reported.
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| 49 |  ;;
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| 50 |  ;;                           OR
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| 51 |  ;;
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| 52 |  ;;   - PTSD symptoms require continuous medication.
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| 53 |  ;;
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| 54 |  ;;                           OR
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| 55 |  ;;
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| 56 |  ;;   - Select all that apply.
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| 57 |  ;;   - PTSD symptoms are not severe enough to require continuous medication.
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| 58 |  ;;   - PTSD symptoms are not severe enough to interfere with occupational
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| 59 |  ;;     and social functioning.
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| 60 |  ;;
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| 61 |  ;;
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| 62 |  ;;   Include your name; your credentials, (i.e., board certified psychiatrist,
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| 63 |  ;;   licensed psychologist, psychiatry resident or psychology intern,
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| 64 |  ;;   LCSW, or NP); circumstances under which you performed the examination,
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| 65 |  ;;   if applicable (i.e., under the close supervision of an attending
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| 66 |  ;;   psychiatrist or psychologist); name of supervising psychiatrist or
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| 67 |  ;;   psychologist, if applicable.
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| 68 |  ;;
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| 69 |  ;;
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| 70 |  ;;Signature:                                               Date:
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| 71 |  ;;
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| 72 |  ;;
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| 73 |  ;;Signature of Supervising
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| 74 |  ;;psychiatrist or psychologist:                            Date:
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| 75 |  ;;END
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