Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) (Page 4 of 7) in pdf

Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) Page 4

Disability Benefits Questionnaire

Initial Post Traumatic Stress Disorder (PTSD)

* Internal VA or DoD Use Only*

SECTION II:

Clinical Findings:

1. Evidence review

In order to provide an accurate medical opinion, the Veteran’s claims folder must be reviewed.

a. Records reviewed (check all that apply):

Claims folder (C-file):

Yes

If no, provide reason C-file was not reviewed: ______________

Other, please describe: ______________________________________

No records were reviewed

b. Was pertinent information from collateral sources reviewed?

Yes

If yes, describe: _______________________

2. History

a. Relevant Social/Marital/Family history (pre-military, military, and post-military): ____________________

b. Relevant Occupational and Educational history (pre-military, military, and post-military): _____________

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military,

military, and post-military: ____________________________________

d. Relevant Legal and Behavioral history (pre-military, military, and post-military): ____________________

e. Relevant Substance abuse history (pre-military, military, and post-military): _______________________

f. Sentinel Event(s) (other than stressors): ___________________________________________________

g. Other, if any: ________________________________________________________________________

Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) Page 4