Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) (Page 3 of 7) in pdf

Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) Page 3

Disability Benefits Questionnaire

Initial Post Traumatic Stress Disorder (PTSD)

* Internal VA or DoD Use Only*

4. Occupational and social impairment

a. Which of the following best summarizes the Veteran’s level of occupational and social impairment with

regards to all mental diagnoses?

(Check only one)

No mental disorder diagnosis

A mental condition has been formally diagnosed, but symptoms are not severe enough either to

interfere with occupational and social functioning or to require continuous medication

Occupational and social impairment due to mild or transient symptoms which decrease work

efficiency and ability to perform occupational tasks only during periods of significant stress, or;

symptoms controlled by medication

Occupational and social impairment with occasional decrease in work efficiency and intermittent

periods of inability to perform occupational tasks, although generally functioning satisfactorily, with

normal routine behavior, self-care and conversation

Occupational and social impairment with reduced reliability and productivity

Occupational and social impairment with deficiencies in most areas, such as work, school, family

relations, judgment, thinking and/or mood

Total occupational and social impairment

b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of

the occupational and social impairment indicated above is caused by each mental disorder?

Yes

no other mental disorder has been diagnosed

If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational

and social impairment is attributable to each diagnosis: _________________________

If yes, list which portion of the indicated level of occupational and social impairment is attributable to each

diagnosis: _________________

c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social

impairment indicated above is caused by the TBI?

Yes

no diagnosis of TBI

If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational

and social impairment is attributable to each diagnosis: _________________________

If yes, list which portion of the indicated level of occupational and social impairment is attributable to each

diagnosis: _________________

Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) Page 3