PTSD DISABILITY WORK CAPACITY EVALUATION QUESTIONS FOR PHYSICIAN

PTSD DISABILITY WORK CAPACITY EVALUATION QUESTIONS FOR PHYSICIAN

Instructions to Client: Take this questionnaire to your Psychiatrist or physician to be filled out and returned to your attorney or vet rep.

Instructions to Physician: Please submit the following information about the patient named above who has applied for a disability based on mental health problems or on PTSD disability before a governmental agency or for other medical reasons such as insurance. The form is designed to be a checklist evaluation to be used by that agency.

Patient Name:

SSN:

Assessment is for:

oWORKERS COMPENSATION

oSOCIAL SECURITY

oVETERANS BENEFITS

Evaluator's Signature:

Date:

Evaluator's Printed Name:

Evaluator's Printed Title (M.D., Ph.D.):

Evaluator's Printed Address

Evaluator's Printed City-State-Zip

1. State your Medical Diagnosis for the patient named above

Axis I

Axis II

Axis III

Axis IV

Axis VI

2. Are any mental health problems of the patient named above service connected either by direct cause incurred by military service, aggravated by military service or secondary to military service?

oYES oNO

3. If “YES” to above, what are these military service connected mental health problems?

o Post Traumatic Stress Disorder

o Organic mental disorders

o Schizophrenic, paranoid, or other psychotic disorder

o Affective disorder

o Mental retardation/Autism

o Anxiety related disorder

o Somatoform disorders

o Personality disorders

o Substance addiction disorder

4. Are any mental health problems of the patient named above PTSD trauma connected either by direct cause incurred by a PTSD trauma event, aggravated by a PTSD trauma event or secondary to a PTSD trauma event (and not connected to Military Service)?

oYES oNO

3. If “YES” to above, what are these PTSD trauma event mental health problems (and not connected to Military Service)?

o Post Traumatic Stress Disorder

o Organic mental disorders

o Schizophrenic, paranoid, or other psychotic disorder

o Affective disorder

o Mental retardation/Autism

o Anxiety related disorder

o Somatoform disorders

o Personality disorders

o Substance addiction disorder

4. Is the patient impaired or disabled from these mental health disorders?

oYES oNO

5. If impaired or disabled from this mental health disorder, state the degree of such impairment or disability:

oNot Significantly Limited

oModerately Limited

oMarkedly Limited

oNo Evidence of Limitation

oNo Ratable Available Evidence

5. On what date did the patient become impaired or disabled from these mental health disorders?

Estimated Date:

6. Is the patient totally and permanently disabled from these service connected disabilities so as to prevent fully competitive work with regular pace and persistence on a regular 40 hour per week basis?

oYES oNO

7. If the answer to the previous question is "YES", on what estimated date did the patient become totally and permanently disabled? Estimated Date:

SYMPTOMS PRESENT AS SET FORTH IN DSM-IV:

(CHECK THE BLANK IF THE CONDITION IS PRESENT)

o A. The person has been exposed to a traumatic event in which both of the following were present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

IDENTIFY THE STRESSORS WHICH CAUSED THIS PTSD CONDITION:

o Military Combat Veteran

o Body Collection Duties of Veteran

o Combat or medical wounds or assaults

o Victim of Crime

o Victim of abuse

o Other (Please describe)

Date(s) of PTSD event:

o B. The traumatic event is persistently re-experienced in at least one of the following ways:

o(1) recurrent and intrusive distressing recollections of the event (in young children, repetitive play in which themes or aspects of the trauma are expressed)

o(2) recurrent distressing dreams of the event

o(3) sudden acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative (flashback) episodes, even those that occur upon awakening or when intoxicated)

o(4) intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma

COMMENTS:

o C. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:

o(1) efforts to avoid thoughts or feelings associated with the trauma

o(2) efforts to avoid activities or situations that arouse recollections of the trauma

o(3) inability to recall an important aspect of the trauma (psychogenic amnesia)

o(4) markedly diminished interest in significant activities (in young children, loss of recently acquired developmental skills such as toilet training or language skills)

o(5) feeling of detachment or estrangement from others

o(6) restricted range of affect, e.g., unable to have loving feelings

o(7) sense of a foreshortened future, e.g., does not expect to have a career, marriage, or children, or a long life

COMMENTS:

o D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:

o(1) difficulty falling or staying asleep

o(2) irritability or outbursts of anger

o(3) difficulty concentrating

o(4) hypervigilance

o(5) exaggerated startle response

o(6) physiologic reactivity upon exposure to events that symbolize or resemble an aspect of the traumatic event (e.g., a woman who was raped in an elevator breaks out in a sweat when entering any elevator)

COMMENTS:

o E. Duration of the disturbance (symptoms in B, C, and D) of at least one month.

COMMENTS:

o Specify delayed onset if the onset of symptoms was at least six months after the trauma.

COMMENTS:

G. If the patient had pre-existing psychiatric problems before military service or the PTSD event (such as personality disorder or schizophrenia), state whether these pre-existing problems presented a significant impairment which would have prevented the patient from performing substantial gainful activity or regular employment or military service: oYES; oNO

H. If the patient had pre-existing psychiatric problems before military service or the PTSD event (such as personality disorder or schizophrenia), state whether these pre-existing problems were aggravated by military service or by the PTSD event: oYES; oNO

I. Are the patient's mental health problems secondary to military service or the PTSD event (such as substance abuse secondary to PTSD or depression secondary to chronic physical pain caused by military service or the PTSD event)? oYES; oNO

MENTAL RESIDUAL FUNCTIONAL CAPACITY

ASSESSMENT BY MEDICAL CONSULTANT

Instructions to Client: Take this questionnaire to your Psychiatrist to be filled out and returned to your attorney or vet rep.

Instructions to Physician: Please submit the following information about the veteran named above who has applied for a disability based on mental health problems or on PTSD disability before a governmental agency. The form is designed to be a checklist type of evaluation to be used by that agency.

Patient Name:

SSN:

Assessment is for:

oWORKERS COMPENSATION

oSOCIAL SECURITY

oVETERANS BENEFITS

Evaluator's Signature:

Date:

Evaluator's Printed Name:

Evaluator's Printed Title (M.D., Ph.D.):

Evaluator's Printed Address

Evaluator's Printed City-State-Zip

1. State your Medical Diagnosis for the patient named above

Axis I Axis III

Axis II Axis IV

Axis V Axis VI

7. The ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances.

9. The ability to work in coordination with or proximity to others without being distracted by them.