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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