Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) (Page 2 of 7) in pdf

Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) Page 2

Disability Benefits Questionnaire

Initial Post Traumatic Stress Disorder (PTSD)

* Internal VA or DoD Use Only*

Diagnosis #3: ______________________

ICD code: __________

Indicate the Axis category:

Axis I

Axis II

Comments, if any: __________________

Diagnosis #4: ______________________

ICD code: __________

Indicate the Axis category:

Axis I

Axis II

Comments, if any: __________________

If additional diagnoses, describe (using above format): ______________

b. Axis III - medical diagnoses (to include TBI): _________________

ICD code: __________

Comments, if any: ____________________

c. Axis IV – Psychosocial and Environmental Problems (describe, if any):________________________

d. Axis V - Current global assessment of functioning (GAF) score: __________

Comments, if any: _______________________

3. Differentiation of symptoms

a. Does the Veteran have more than one Mental disorder diagnosed?

Yes

If yes, complete the following question:

b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?

Yes

Not applicable (N/A)

If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to

each diagnosis: _________________________

f yes, list which symptoms are attributable to each diagnosis: _________________

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

Yes

Not shown in records reviewed Comments, if any: _____________

If yes, complete the following question:

d. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?

Yes

Not applicable (N/A)

If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to

each diagnosis: _________________________

If yes, list which symptoms are attributable to each diagnosis: _________________

Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) Page 2