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

Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) Page 7

Disability Benefits Questionnaire

Initial Post Traumatic Stress Disorder (PTSD)

* Internal VA or DoD Use Only*

5. Symptoms

For VA rating purposes, check all symptoms that apply to the Veterans diagnoses:

Depressed mood

Anxiety

Suspiciousness

Panic attacks that occur weekly or less often

Panic attacks more than once a week

Near-continuous panic or depression affecting the ability to function independently, appropriately

and effectively

Chronic sleep impairment

Mild memory loss, such as forgetting names, directions or recent events

Impairment of short- and long-term memory, for example, retention of only highly learned material,

while forgetting to complete tasks

Memory loss for names of close relatives, own occupation, or own name

Flattened affect

Circumstantial, circumlocutory or stereotyped speech

Speech intermittently illogical, obscure, or irrelevant

Difficulty in understanding complex commands

Impaired judgment

Impaired abstract thinking

Gross impairment in thought processes or communication

Disturbances of motivation and mood

Difficulty in establishing and maintaining effective work and social relationships

Difficulty in adapting to stressful circumstances, including work or a worklike setting

Inability to establish and maintain effective relationships

Suicidal ideation

Obsessional rituals which interfere with routine activities

Impaired impulse control, such as unprovoked irritability with periods of violence

Spatial disorientation

Persistent delusions or hallucinations

Grossly inappropriate behavior

Persistent danger of hurting self or others

Neglect of personal appearance and hygiene

Intermittent inability to perform activities of daily living, including maintenance of minimal personal

hygiene

Disorientation to time or place

6. Other symptoms

Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not

listed above?

Yes

If yes, describe: ___________________________________________________

7. Competency

Is the Veteran capable of managing his or her financial affairs?

Yes

If no, explain: __________________________

8. Remarks, if any ___________________________________________________________________________

Psychiatrist/Psychologist signature & title: _________________________________ Date: ___________________

Psychiatrist/Psychologist printed name: ___________________________________ Phone: _________________

NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA’s

review of the Veteran’s application.

Disability Benefits Questionnaire - Initial Post Traumatic Stress Disorder (Ptsd) Page 7

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