bob’s most excellent dbq redact - wordpress.com

INTERNALVETERANSAFFAIRS USEINITIAL POST TRAUMATIC STRESS DISORDER (PTSD)

DISABILITY BENEFITS QUESTIONNAIRE

IMPORTANT -- THEDEPARTMENTOF VETERANS AFFAIRS (VA) WILL NOTPA Y OR RETMBURSEANY EXPENSES OR COST INCURREDIN THEPROCESS OF COMPLETINGAND/ORSUBMITTINGTHIS FORM. PLEASE READ THEPRIVACY ACT AND RESPONDENTBURDENINFORMATIONBEFORE COMPLETINGTHISFORM.

NAME OF PATIENTIVETERAN PATIENTIVETERAN'SSOCIAL SECURITYNUMBERXXX-

Your patient is applying to the U. S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire as partof their evaluation in processing the Veteran's claim. Please note that this questionnaire is for disability evaluation, not for treatment purposes. This evaluation should bebased on DSM-5 dia:nostic criteria

NOTE: If the Veteran experiences a mental health emergency dunng the interview, please tenninate the interview and obtain help, using local resources as appropriate.You may also contact the Veterans Crisis Line at 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the Veteran to emergency care.

Mental Health professionals with the following credentials are qualified to perform review C&Pexaminations for mental disorders. They are: a Board Certifiedpsychiatrist; psychiatrist who have successfully completed an accredited psychiatry residency and who are appropriately credential and privileged; licensed doctorate-levelpsychologist; non-licensed doctorate level psychologists working toward licensure under close supervision by a board certified or board eligible psychiatrist or licenseddoctoral level psychologist; psychiatry resident under close supervision by a board-certified or board eligible psychiatrist or licensed doctoral level psychologist;psychology residents under close supervision by a board eligible psychiatrist or a licensed doctoral level psychologist. .

Note: Close supervision means that the supervising psychiatrist or psychologist met with the Veteran and conferred with the examining mental health professional inprovidm.. the dia-nosis and the final assessment The supervismasschiatrist or ps, cholot ist co-stens the exammation report.

SECTIONI - DIAGNOSTICSUMMARY1. DIAGNOST1C SUMMARYThis section should be completed based on the current exammation and clmical findmgs.

DOES THEVETERAN HAVE A DIAGNOSISOF PTSD THAT CONFORMSTO DSM-5 CRITERIABASED ON TODAY'S EVALUATION?

YEs O NO ICD CODE: F43.1

If no diagnosis of PTSD,check all that apply:

O veteran s symptoms do not meet the diagnostic criteria for PTSDunder DSM-5 criteria

O Veteran does not have a mental disorders that conforms with DSM-5 criteria

O Veteran has another mental disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorders Questionnaire

2. CURRENTDIAGNOSES

2A. Mental Disorders Diagnosis #1: PTSDICD CODE: F43.1

COMMENTS,IF ANY:Mental Disorders Diagnosis #2:

ICD CODE:COMMENTS,IF ANY:

Mental Disorders Diagnosis #3:

ICD CODE:COMMENTS,IF ANY:

Mental Disorders Diagnosis #4:ICD CODE:COMMENTS,IF ANY:

IF ADDITIONALDIAGNOSES,DESCRIBEUSINGABOVE FORMAT:

2B. MEDICALDIAGNOSESRELEVANTTO THE UNDERSTANDINGOR MANAGEMENTOF THE MENTALHEALTH DISORDER(to include TBI):

Chronic pain in shoulder, elbows.

ICD CODE: Unknown.

COMMENTS,IF ANY:

Claimant Name : HANNA ROBERT Account Number : 2660833.3.1 Date of Examination : 12/23/2019For internal VA Use Updated on: May 22, 2018

PTSD Initial Disability Benefits Questionnaire Aligns with CAPRI version:05/22/2018"v18_1_Final Page1

3. DIFFERENTIAT10NOF SYMPTOMS

3A. DOESTHE VETERAN HAVE MORETHAN ONE MENTAL DISORDERDIAGNOSED?

O YES NO (If "Yes," complete Item 38)

3B. IS IT POSSIBLETO DIFFERENTIATEWHAT SYMPTOM(S)IS/AREATTRIBUTABLETO EACH DIAGNOSIS?

O YES O NO O NOT APPLICABLE(If "No," provide mason):

(If "Yes," list which symptoms are affributable to each diagnosis and discuss whether there is any clinical association between these diagnoses):

3C. DOESTHE VETERAN HAVE A DIAGNOSEDTRAUMATIC BRAIN INJURY (TBI)?

O YES O NO NOT SHOWN IN RECORDSREVIEWED (If "Yes,"complete Item 3D)(Comments, if any):

3D. IS IT POSSIBLETO DIFFERENTIATEWHAT SYMPTOM(S)ISIAREATTRIBUTABLETO TBI AND ANY NON-TBIMENTALHEALTH DIAGNOSIS?

O YES O NO O NOT APPLICABLE(If "No," pmvide mason):

(If "Yes," list which symptoms are attributable to TBI and which symptoms are attributable to a non-TBI mental health diagnosis):

4. OCCUPATIONALAND SOCIAL IMPAIRMENT

4A. WHICH OF THE FOLLOWINGBEST SUMMARIZESTHE VETERAN'SLEVEL OF OCCUPATIONALAND SOCIAL IMPAIRMENTWITH REGARDSTO ALL MENTAL DIAGNOSES?(Check only one)

O NO MENTAL DISORDERDIAGNOSIS

O A MENTALCONDITIONHAS BEEN FORMALLY DIAGNOSED,BUT SYMPTOMSARE NOT SEVERE ENOUGHEITHERTO INTERFEREWITHOCCUPATIONALAND SOCIAL FUNCTIONINGOR TO REQUIRECONTINUOUSMEDICATION

O OCCUPATIONALAND SOCIAL IMPAIRMENTDUE TO MILD OR TRANSIENTSYMPTOMSWHICH DECREASEWORK EFFICIENCYAND ABILITYTO PERFORMOCCUPATIONALTASKS ONLY DURINGPERIODSOF SIGNIFICANTSTRESS,OR SYMPTOMSCONTROLLEDBY MEDICATION

O OCCUPATIONALAND SOCIAL IMPAIRMENTWITH OCCASIONALDECREASEIN WORK EFFICIENCYAND INTERMITTENTPERIODSOFINABILITYTO PERFORMOCCUPATIONALTASKS, ALTHOUGHGENERALLY FUNCTIONINGSATISFACTORILY,WITH NORMAL ROUTINEBEHAVIOR,SELF-CAREAND CONVERSATION

O OCCUPATIONALAND SOCIAL IMPAIRMENTWITH REDUCEDRELIABILITYAND PRODUCTIVITY

OCCUPATIONALAND SOCIAL IMPAIRMENTWITH DEÈICIENCIESIN MOSTAREAS. SUCH AS WORK, SCHOOL, FAMILY RELAl lONSJUDGMENT.THINKINGANDIOR MOOD

O TOTAL OCCUPATIONALAND SOCIAL IMPAIRMENT

4B. FOR THE INDICATEDOCCUPATIONALAND SOCIAL IMPAIRMENT,IS IT POSSIBLETO DIFFERENTIATEWHICHIMPAIRMENTIS CAUSEDBY

EACH MENTALDISORDER?

O YES O NO NOT APPLICABLE(If "No,"provide reason):

(If "Yes," list which occupational and social impainnent is attributable to each diagnosis):

4C. IF A DIAGNOSISOF TBI EXISTS, IS IT POSSIBLETO DIFFERENTIATEWHICHOCCUPATIONALAND SOCIAL IMPAIRMENTINDICATEDABOVEIS CAUSED BY THE TBI?

O YES O NO NOT APPLICABLE(If "No," provide reason):

(If "Yes," list which impairment is attributable to TBIand which is attributable to any non-TBI mental health diagnosis):

Claimant Name :of Examination : 12/23/2019

For Internal VA Use Updated on: May 22, 2018

PTSD Initial Disability Benefits Questionnaire Aligns with CAPRI version: 05/22/2018"v18_1_Final Page2

SECT10N II - CLINICAL FINDINGS

1. EVIDENCEREVIEWIn order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed.

Evidence reviewed (check all that apply):

0 Not requested O No records were reviewed

O VA claims file (hard copy paper C-file)VA e-folder

O CPRSO Other (please identify other evidence reviewed):

Evidence Comments:A report by staff physician James Proffitt, M.D., refers to prior diagnoses of PTSD and depression forwhich the veteran had received needed treatment. This was at the PortlandVA dated August 7, 2018. Physician Thomas McAnally referred to PTSD, anxiety and depression on February 17, 2000 at the WainwrightVA MC in Walla Walla Washington. Theveteran was considered to meet the criteria for PTSD by John Grizzle, PhD, clinical psychologist dated September 27, 2017 at the Portland VA.

2. HISTORYNOTE: Imtlal exammations re pwre Tre-mihon m1ht in, and

;ost-miht a luston Iftlus is a review exammation onh mdicate an relevant histon smee inor exam.

2A. RELEVANT SOCIAL/MARITALIFAMILY HISTORY (pre-military, military, and post-military).

The veteran describes a childhood notable for getting along well with his brother, two sisters and with both parents, neither of whom were drug addicts or alcoholics. He has beenmarried twice but is divorced. He has one adult daughter. He lives alone in a trailer house on an acre of property. He doesn't have many friends, other than a few neighbors.

2B. RELEVANTOCCUPATIONAL AND EDUCATIONAL HISTORY (pre-military, military, and post-military):

He had average high school grades and eamed a diploma. He has taken a few classes in radio broadcasting and hotellmotel hospitality and in heavy trucking. He had unskilledlaboring jobs prior to military service at age 18. He has had many different jobs since then including managing stores and working as a heavy truck driver. He and his brother hadtheir own trucking company for about five or 10 years. He has been retired for about six years secondary to physical problems including right shoulder problems and both elbowproblems. He is on SSD as a result.

2C. RELEVANTMENTALHEALTH HISTORY, TO INCLUDE PRESCRIBED MEDICATIONS AND FAMILY MENTAL HEALTH (pre-military, military, and post-military):

He describes his military service as emotionally stressful secondary to transporting deceased veterans in Air Force planes and moving injured veterans to hospital areas in AirForce planes. He still has nightmares about these experiences. His only current medication is mirtazapine, 15 mg in the evening. He has had anger management and othercounseling which he has taken seriously and tries to apply but continues to have concems about his low stress tolerance and anger feelings, anxiety and panic attacks in socialsituations,such as crowds. He has nightmares, which are lessened a little bit with his medication and with cannabis. He has had anger management classes in Bend. He hassuicidal fantasies of driving off of roads or into other traffic. He would like supportive counseling for these psychiatric problems.

2D. RELEVANTLEGAL AND BEHAVIORAL HISTORY (pre-military, military, and post-military):

He has been in jail twice, once when on leave in the service for possessing pot and a second time for a motor vehicle accident apparently when mildly inebriated. He was in theReno jail for 30 days for this second offense and is still on probation for it. This occurred in June 2017.

2F. OTHER (If any):In interview he talks rather constantly about his various problems, apparently an expression of anxiety and an inmate sense that talking about problems may help to resolve them

Claimant Name : Date of Examination : 12/23/2019For Internal VA Use Updated on: May 22, 2018

PTSD Initial Disability Benefits Questionnaire Aligns with CAPRI version:05/22/2018,t18_1_Final Page3

e

3. STRESSORSThe 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 altillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft.

Describe one or more specific stressor event is) the Veteran considers traumatic n be pre-military, military, or post-military):

3A. Stressor #1

His stressor is just the burden of dealing with presumably hundreds of deceased veterans in coffins and storing them on aircraft for shipment back to the

United States and also loading injured veterans on to aircraft for shipping to treatment hospitals from Vietnam. He still has troubling nightmares about these

experiences.

Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?YES O NO

Is the stressor related to the Veteran's fear of hostile military or terrorist activity?

O YES NOIf no, explain:This does not have to do with you directly military combat.

Is the stressor related to in-service personal assault, e.g. military sexual trauma?

O YES NOIf yes, please describe the markers that may substantiate the stressor.

3B. Stressor #2

Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?O YES O NO


O YES O NOIf no, explain:

Is the stressor related to in-service personal assault, e.g., military sexual trauma?

O YES O NOIf yes, please describe the markers that may substantiate the stressor.

Claimant Name :Date of Examination : 12/23/2019


PTSD Initial Disability Benefits Questionnaire Aligns with CAPRI version:05/22/2018~v18_1_Final Page4

3. STRESSORS3C. Stressor #3

Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?O YES O NO


O YEs O NOIf no, explain:

Is the stressor related to in-service personal assault, e.g., military sexual trauma?O YES O NO

If yes, please describe the markers that may substantiate the stressor.

3D. Additional Stressors: If additional stressors, describe (list using above sequential format)

4. PTSD DIAGNOSTICCRITERIANOTE: Please check criteria used for establishing the current PTSD diagnosis. Do mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead,overlapping symptoms clearly attributable to other things should be noted under #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criteria A-H, are from the Diagnostic andStatistical Manual of Mental Disorders 5th edition DSM-5.

Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways:

Directly experiencing the traumatic event(s)

O Witnessing, in person, the traumatic event(s) as they occurred to others

O Leaming that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent oraccidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains;police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures,unless this exposure is work related

O No criterion in this section met.

Claimant Name : Date of Examination : 12/23/2019For Internal VA Use Updated on: May 22, 2018


4. PTSD DIAGNOSTICCRITERIACriterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s)occurredO Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

O Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a

continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

O Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

O Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).


Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after traumatic event(s) occurred, as evidence of one or bothof the following:

O Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Avoidance of or efforts to avoid extemal reminders (people, places, conversations, activities, objects, situations) that arouse distressing memones,thoughts, or feelings about or closely associated with the traumatic event(s).


Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s)occurred, as evidenced by two (or more) of the following:

O Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury,

alcohol, or drugs).Persistent and exaggerated negative beliefs oi expectations about oneself, others, oi the world (e.g., "I am bad,: "No one can be trusted.: "The world is

completely dangerous.: "My whole nervous system is permanently ruined").

O Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himselflherself or others.

Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

O Markedly diminished interest or participation in significant activities.Feelings of detachment or estrangement from others.Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.)


Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s)occurred, as evidenced by two (or more) of the following:

Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

Reckless or self-destructive behavior.

O Hypervigilance.

O Exaggerated startle response.

O Problems with concentration.

O Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).


Criterion F:

Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month


Criterion G:The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

No criterion in this section met.

Criterion H:

The disturbance is not attributable tothe physiological effects of a substance te g ,medication, alcohol) or another medical condition.


Criterion I: Which stressor(s) contributed to the Veterans PTSD diagnosis?:Stressor #1

O Stressor #2

O stressor #aO Other, please indicate stressor number (i.e. stressor #5, #6, etc.) as indicated above:


Claimant Name :of Examination : 12/23/2019


PTSD Initial Disability Benefits Questionnaire Aligns with CAPRI version:05/22/2018~v18_1_Final Page6

5. SYMPTOMS

FOR VA RATING PURPOSES,CHECKALL SYMPTOMSTHAT APPLY TO THE VETERAN'S DIAGNOSES:Depressed mood

M AnxietyO suspiciousness

Panic attacks that occur weekly or less often

O Panic attacks more than once a week

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

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

O Impairment of short and long term memory, for example, retention of only highly leamed material, while forgetting to complete tasks

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

O Flattened affect

O circumstantial, circumlocutory or stereotyped speech

O Speech intermittently illogical, obscure, or irrelevant

O Difficulty in understanding complex commands

O Impaired judgmentO Impaired abstract thinking

O Gross impairment in thought processes or communicationDisturbances of motivation and moodDifficulty in establishing and maintaining effective work and social relationships

O Difficulty adapting to stressful circumstances, including work or a work like setting

O Inability to establish and maintain effective relationshipsGulcidal ideation

O Obsessional rituals which interfere with routine activities

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

O Spatial disorientation

O Persistent delusions or hallucinations

O Grossly inappropriate behavior

O Persistent danger of hurting self or others

O Neglect of personal appearance and hygiene

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

O Disorientation to time or place

6. BEHAVIORAL OBSERVATIONS

He was on time for his scheduled appointment, having driven himself over 100 miles. He was appropriately dressed and groomed and related in a friendlyand cooperative manner. He seemed anxious in that he talked constantly unless stopped by the examiner. He seemed preoccupied with personal problemsinvolving social anxiety and feelings of depression and worthlessness. He was not unduly irritable per se.

7. OTHERSYMPTOMS

DOESTHEVETERAN HAVE ANY OTHERSYMPTOMSATTRIBUTABLETO PTSD (AND OTHERMENTALDISORDERS)THAT ARE NOT LISTEDABOVE?

O YES NO (If"Yes,"describe):

Claimant Name : of Examination : 12/23/2019For Internal VA Use Updated on: May 22, 2018

PTSD Initial Disability Benefits Questionnaire Aligns with CAPRI version: 05/22/2018"v18_1_Final Page7

8. COMPETENCY

IS THE VETERAN CAPABLE OF MANAGINGHIS OR HER FINANCIALAFFAIRS?

lEl YES O NO (if "No,"explain):

9. REMARKS, (including any testing results) IF ANY

The claimant does not appear to pose any threat of danger or injury to self or others.For the claimant's claimed condition of POST TRAUMATICSTRESSDISORDERplease refer to the diagnosis section.

The veteran completed the examiner's suicide proneness scale and had 21 elevated scores, well above the cutoff of 15 or 16 scores that separates non-suicidal from suicidal clinical patients. He had elevations on high self-achievement goals, high financial pressure, lacking problem-sharing habits, lackingconfidant friends and support request skills, lacking hobby time, exercise time and adequate sleep, suffering chronic pain and chronic anxiety, sufleringchronic depression and guilt feelings, having weak emotion-handling skills, having mental health problems and substance abuse habits, having angermanagementproblems and loneliness and hopeless feelings, lacking goals and friends and endorsing suicidal thoughts and plans.

DESIGNATEDVA MATERIAL REGARDINGVETERAN / MILITARYCRISISCONTACTINFORMATIONHAS BEENPROVIDEDTO THEVETERAN /

SERVICEMEMBER.

SECTION III- PSYCHIATRISTIPSYCHOLOGISTCERTIFICATIONAND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

10A. PSYCHIATRIST/PSYCHOLOGIST SIGNATURE AND TITLE 10B. PSYCHIATRIST/PSYCHOLOGIST PRINTED NAME 10C. DATE SIGNEDPH.D Psychology 12/23/2019 (UTC)

fa07f363-1383-40db-8040-bdec3a55842110D. PSYCHIATRIST/PSYCHOLOGIST PHONE AND 10E. PSYCHIATRIST/PSYCHOLOGIST NATIONAL 10F. MEDICAL LICENSE NUMBER AND STATEFAX NUMBERS PROVIDER IDENTIFIER (NPI) NUMBER

10G. PSYCHIATRIST/PSYCHOLOGIST ADDRESS1679 WILLIAMETEST EUGENE OR 97401

Claimant Name : : 12/23/2019For Internal VA Use Updated on: May 22, 2018


bob’s most excellent dbq redact - wordpress.com

Documents