Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) Page 5
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7Disability Benefits Questionnaire
Initial Post Traumatic Stress Disorder (PTSD)
* Internal VA or DoD Use Only*
3. Stressors
The stressful event can be due to combat, personal trauma, other life threatening situations (non-combat
related stressors).
NOTE: For VA purposes, “fear of hostile military or terrorist activity” means that a veteran experienced,
witnessed, or was confronted with an event or circumstance that involved actual or threatened death or
serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or
potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or
mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft,
and the veteran's response to the event or circumstance involved a psychological or psycho-physiological
state of fear, helplessness, or horror.
Describe one or more specific stressor event (s) the Veteran considers traumatic(may be pre-military,
military, or post-military):
a. Stressor #1: _______
____________
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
Yes
No
Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?
Yes
No
If no, explain: ________________
b. Stressor #2: ___________________
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
Yes
No
Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?
Yes
No
If no, explain: ________________
c. Stressor #3: ___________________
Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
Yes
No
Is the stressor related to the Veteran’s fear of hostile military or terrorist activity?
Yes
No
If no, explain: ________________
d. Additional stressors: If additional stressors, describe (list using the above sequential format): _________
4. PTSD Disgnostic Criteria
a. Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for
PTSD, referred to as Criteria A-F, are from the Diagnostic and Statistical Manual of Mental Disorders, 4th
edition (DSM-IV).
Criterion A: The Veteran has been exposed to a traumatic event where both of the following were present
The Veteran experienced, witnessed or was confronted with an event that involved actual or
threatened death or serious injury, or a threat to the physical integrity of self or others.
The Veteran’s response involved intense fear, helplessness or horror.
No exposure to a traumatic event.
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