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Found 159 results

  1. Greetings ladies and gentlemen, I received a 70% rating for PTSD from last years increase when it was at 50%. I've been unemployed for over a year since being fired for several aggressive angry outbursts related to stressors tied to my PTSD. Filed for TDIU May 11th of 2016 and I have a C&P scheduled for June 10th of 2016. What the heck can I expect at a TDIU c&p? I sent in all of my formal write-ups and suspension paperwork from my previous employer as well as buddy statements from coworkers who witnessed my behavior and how my work performance was affected due to PTSD. I have tried multiple times to have HR from my previous employer fill out the VA-form requesting employment info but they have not cooperated with me. Won't return calls or emails. Even sent them the form but nothing gets back to me. I fear that will hurt me and also be I'm clean shaven and well dressed (I'm ocd about my appearance by it seems as if it's the only thing I can control). I stay home taking care of my daughter but she goes to daycare a couple times a week to give me a break. It gets too much at times. Should that be mentioned ? I just thought my claim is moving fast and not sure if that is good or bad ? Any thoughts? Thanks for all you do. It is greatly appreciated.
  2. Hi everyone I am new here, and after reading some of these C&P stories I am pretty upset to say the least. I find myself here because I recently received a letter in the mail stating I had an appointment for a C&P, but the letter does not in any way say what it is for. I logged on to the EBenefits website because I check there once a week, and found my claim completion estimation had been pushed back by between 5-8 months with no information about why. So I went to check out my documents section I than went to generation my summary of benefits and it says my combined service-connected evaluation is 90% and it says my effective date was February 1st of 2016. I never received a packet or any sort of breakdown never received any money, so why do I need to do another C&P if I've done all my documents?
  3. Hey guys! Seems like I been away from you guys for a while now, so I knew I needed to login and share some updates with my fellow hadit.com vets! I had my final C&P Exam--Hearing Loss/Tinnitus last Monday April 18th. I checked eBennies last nite 04/285/16, and my claim is now in the Prepped for Decision: New Documents Rcvd--Development letter Sent, so I'm happy to see that its been moving faster than I originally expected or had hoped it would be. After all, I submitted my claims about 73 days ago and my estimated completion time was 06/22/16 to 10/122/2016 and now its 05/22/16 to 06/23/2016!! Sooooo...I been busy with other things to this point and even now and not sure how I shold be feeling when it appears to be moving so fast now. With that being said, I had three exams (TBI Residuals--HA's/PTSD/Tinnitus) and I only seen that my VARO has only recvd or showing 2 of 3 exams in eBennies today when I logged in. So, what does that mean if the PTSD DBQ wasn't shown & the TBI Residuals--Headaches & Tinnitus were, with it being in the PFD stage? Semper Paratus
  4. I had this C& P done on the 16th. From start to finish was 1hr and 45 mins. the doctor hardly touched me and looked mostly at her computer. the statement about me having flat feet going into boot camp. I am not sure how she came to that because I didn't tell her that. Any feedback or suggestions would be helpful. I have my PTSD C& P on the 26th. Thank You! Gulf War General Medical Examination Disability Benefits Questionnaire * Internal VA or DoD Use Only* 1. Medical record review ------------------------ [X] Other, describe: VBMS 2. Medical history ------------------ a. No symptoms, abnormal findings or complaints: No answer provided b. Skin and scars: No answer provided c. Hematologic/lymphatic: No answer provided d. Eye: No answer provided CONFIDENTIAL Page 5 of 43 e. Hearing loss, tinnitus and ear: Hearing Loss and Tinnitus f. Sinus, nose, throat, dental and oral: Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx g. Breast: No answer provided h. Respiratory: Respiratory Conditions (other than tuberculosis and sleep apnea) i. Cardiovascular: No answer provided j. Digestive and abdominal wall: Intestinal Conditions (other than Surgical and Infectious) k. Kidney and urinary tract: No answer provided l. Reproductive: Gynecological Conditions m. Musculoskeletal: The following conditions have been reported Joints and extremities: Ankle Feet: Flatfeet n. Endocrine: No answer provided o. Neurologic: No answer provided p. Psychiatric: PTSD (Initial or Review) q. Infectious disease, immune disorder or nutritional deficiency: No answer provided r. Miscellaneous conditions: No answer provided 3. Diagnosed illnesses with no etiology --------------------------------------- From the conditions identified and for which Questionnaires were completed, are there any diagnosed illnesses for which no etiology was established? [ ] Yes [X] No 4. Additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- CONFIDENTIAL Page 6 of 43 Does the Veteran report any additional signs and/or symptoms not addressed through completion of DBQs identified in the above sections? [ ] Yes [X] No 5. Physical Exam ---------------- Normal PE, except as noted on additional Questionnaires included as part of this report 6. Functional impact of additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness" ----------------------------------------------------------------------------- [ ] Yes [X] No 7. Remarks, if any: ------------------- E-file reviewed including buddy statement. Veteran does have fatigue and trouble sleeping that should be further examined with PTSD exam by mental health examiner for insomnia. Veteran reports she had a cold and URi multiple times while in service. She was given an inhaler and was told she hadd possible exercise induced asthma but it only seemd to flare up during change in seasons and was related to more of her sinuses and rhinitis. See rhinitis and sinusitis exam for more information on her "respiratory" complaint. **************************************************************************** Intestinal Conditions (other than surgical or infectious), including irritable bowel syndrome, Crohn's disease, ulcerative colitis and diverticulitis Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No CONFIDENTIAL Page 7 of 43 ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with an intestinal condition (other than surgical or infectious)? [X] Yes [ ] No [X] Irritable bowel syndrome ICD code: K58.0 Date of diagnosis: 2004 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's intestinal condition (brief summary): Veteran reports constipation started while in boot camp in 2004. The diarrhea started while in Iraq in 2009. It alternated dairrhea and constipation. She saw a GI doctor in 2009 and she took Miralax and another medication for ulcers. She tested negative for h. pylori and ova and aprasites and those were negative. She avoided food triggers and alternated between culcolax and miralax and imdoium. Symptoms continue to the present day. She was also given zofran for nausea. b. Is continuous medication required for control of the Veteran's intestinal condition? [X] Yes [ ] No If yes, list only those medications required for the intestinal condition: miralax imodium probiotics c. Has the Veteran had surgical treatment for an intestinal condition? CONFIDENTIAL Page 8 of 43 [ ] Yes [X] No 3. Signs and symptoms --------------------- Does the Veteran have any signs or symptoms attributable to any non-surgical non-infectious intestinal conditions? [X] Yes [ ] No If yes, check all that apply: [X] Alternating diarrhea and constipation If checked, describe: alternating diarrhea and constipation but it varies. Usually at all 2-3 days of diarrhea followed by almost a week of not going [X] Abdominal distension If checked, describe: swollen abdomen, appears 2-3 months pregnant usually. Cramping and gurgling in the stomac [X] Nausea If checked, describe: feels sick to stomach [X] Vomiting If checked, describe: takes zofran [X] Other, describe: passes out and sweats sometimes and has sharp pains ont he left side of abdomen 4. Symptom episodes, attacks and exacerbations ---------------------------------------------- Does the Veteran have episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition? [X] Yes [ ] No If yes, indicate severity and frequency: (check all that apply) [X] Episodes of bowel disturbance with abdominal distress If checked, indicate frequency: [ ] Occasional episodes [X] Frequent episodes CONFIDENTIAL Page 9 of 43 [ ] More or less constant abdominal distress 5. Weight loss -------------- Does the Veteran have weight loss attributable to an intestinal condition (other than surgical or infectious condition)? [ ] Yes [X] No 6. Malnutrition, complications and other general health effects --------------------------------------------------------------- Does the Veteran have malnutrition, serious complications or other general health effects attributable to the intestinal condition? [ ] Yes [X] No 7. Tumors and neoplasms ----------------------- a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? [ ] Yes [X] No 8. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: 9. Diagnostic testing --------------------- a. Has laboratory testing been performed? [ ] Yes [X] No b. Have imaging studies or diagnostic procedures been performed and are the results available? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No 10. Functional impact --------------------- Does the Veteran's intestinal condition impact his or her ability to CONFIDENTIAL Page 10 of 43 work? [X] Yes [ ] No If yes, describe the impact of each of the Veteran's intestinal conditions, providing one or more examples: frequent bathroom breaks 11. Remarks, if any: -------------------- E-file reviewed. Veteran's IBS is a diagnosable chronic multisymptom illness with a partially explained etiology that is at least as likely as not related to an exposure event in Southwest Asia as symptoms did not start until she was in Iraq. **************************************************************************** Sinusitis, Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes[ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS SECTION I: Diagnosis: CONFIDENTIAL Page 11 of 43 --------------------- Does the Veteran now have or has he/she ever been diagnosed with a sinus, nose, throat, larynx, or pharynx condition? (This is the condition the Veteran is claiming or for which an exam has been requested) [X] Yes [ ] No [X] Chronic sinusitis ICD code: J32.9 Date of diagnosis: 2004 [X] Allergic rhinitis ICD code: 477.9 Date of diagnosis: 2004 SECTION II: Medical history --------------------------- Veteran reports she had drainage and a head cold with stuffiness and she was treated with sudafed and tessalon perles. She had been coughing and had a sore throat and the congestion was in her chest so at night she would have a hard time breathing and had a hard time breathing when running. She was given an inhaler and nasal spray and allergy meds which helped. She had questionable exericse induced asthma, btu she notes it was only when she had a cold or sinus infection that she had the breathing problems. The allergies and rhinitws continue to the prfesent day. She gets URI at least 3 times througout the year. SECTION III: Nose, throat, larynx or pharynx conditions ------------------------------------------------------- Does the Veteran have any of the following nose, throat, larynx or pharynx conditions? [X] Yes [ ] No [X] Sinusitis [X] Rhinitis 1. Sinusitis ------------ a. Indicate the sinuses/type of sinusitis currently affected by the Veteran's chronic sinusitis (check all that apply): [ ] None [X] Maxillary [ ] Frontal [ ] Ethmoid [ ] Sphenoid [ ] Pansinusitis b. Does the Veteran currently have any findings, signs or symptoms attributable to chronic sinusitis? [X] Yes [ ] No If yes, check all that apply: [ ] Chronic sinusitis detected only by imaging studies (see Diagnostic testing section) [X] Episodes of sinusitis [ ] Near constant sinusitis If checked, describe frequency: CONFIDENTIAL Page 12 of 43 [X] Headaches [X] Pain of affected sinus [X] Tenderness of affected sinus [X] Purulent discharge [ ] Crusting [ ] Other For all checked conditions, describe: c. Has the Veteran had NON-INCAPACITATING episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months? [X] Yes [ ] No If yes, provide the total number of non-incapacitating episodes over the past 12 months: [ ] 1 [ ] 2 [X] 3 [ ] 4 [ ] 5 [ ] 6 [ ] 7 or more d. Has the Veteran had INCAPACITATING episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months? [ ] Yes [X] No NOTE: For VA purposes, an incapacitating episode of sinusitis means one that requires bed rest and treatment prescribed by a physician. If yes, provide the total number of incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotic treatment over past 12 months: [ ] 1 [ ] 2 [ ] 3 or more e. Has the Veteran had sinus surgery? [ ] Yes [X] No If yes, specify type of surgery: [ ] Radical (open sinus surgery) [ ] Endoscopic [ ] Other: Type of procedure, sinuses operated on and side(s): Date(s) of surgery (if repeated sinus surgery, provide all dates of surgery): If Veteran has had radical sinus surgery, did chronic osteomyelitis follow the surgery? [ ] Yes [ ] No f. Has the Veteran had repeated sinus-related surgical procedures performed? [ ] Yes[X] No 2. Rhinitis ----------- CONFIDENTIAL Page 13 of 43 a. Is there greater than 50% obstruction of the nasal passage on both sides due to rhinitis? [ ] Yes [X] No b. Is there complete obstruction on the left side due to rhinitis? [ ] Yes [X] No c. Is there complete obstruction on the right side due to rhinitis? [X] Yes [ ] No d. Is there permanent hypertrophy of the nasal turbinates? [X] Yes [ ] No e. Are there nasal polyps? [ ] Yes [X] No f. Does the Veteran have any of the following granulomatous conditions? [ ] Yes [X] No If yes, check all that apply: [ ] Granulomatous rhinitis [ ] Rhinoscleroma [ ] Wegener's granulomatosis [ ] Lethal midline granuloma [ ] Other granulomatous infection, describe: 6. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to the conditions listed in the Diagnosis Section above? [ ] Yes[X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes[X] No c. Comments, if any: No answer provided d. Does the Veteran have loss of part of the nose or other scars of the nose exposing both nasal passages? [ ] Yes[X] No e. Does the Veteran have loss of part of the nose or other scars causing loss of part of one ala? [ ] Yes[X] No f. Does the Veteran have loss of part of the nose or other scars causing CONFIDENTIAL Page 14 of 43 other obvious disfigurement? [ ] Yes[X] No SECTION IV: Diagnostic testing ------------------------------ a. Have imaging studies of the sinuses or other areas been performed? [ ] Yes[X] No b. Has endoscopy been performed?: No c. Has the Veteran had a biopsy of the larynx or pharynx?: No d. Has the Veteran had pulmonary function testing to assess for upper airway obstruction due to laryngeal stenosis?: No e. Are there any other significant diagnostic test findings and/or results? No answer provided SECTION V: Functional impact and remarks ---------------------------------------- 1. Functional impact -------------------- Does the Veteran's sinus, nose, throat, larynx or pharynx condition impact his or her ability to work? [ ] Yes [X] No 2. Remarks, if any: ------------------- E-file reviewed. Veteran's rhinits and sinusitis is a diagnosable chronic multisymptom illness with a partially explained etiology that is at least as likely as not related to an exposure event in Southwest Asia as symptoms did not start until she was in Iraq and she was exposed to noxious fumes and dust storms which negatively impact the sinuses and cause chronic inflammation. **************************************************************************** Ankle Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? CONFIDENTIAL Page 15 of 43 [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: ankle strain b. Select diagnoses associated with the claim condition(s) (Check all that apply): [X] Other (specify): Other diagnosis: ankle strain ICD Code: 845 Side affected: Both Date of diagnosis: Right:2004 Date of diagnosis: Left:2004 ******************************************************************** c. Comments (if any): No response provided 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's ankle condition (brief summary): Veteran reports she rolled her ankles while in boot camp a few times and had shin splints and she has had ongoing ankle pain since. She did physical therapy before which helped. The pain contineus to the present day. b. Does the Veteran report flare-ups of the ankle? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or CONFIDENTIAL Page 16 of 43 her own words: ankles give out on her at times. Dull and achy pain. Swells by the end off the day. c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: has to take breaks or sit after prolonged standing 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion Right ankle ----------- [X] All Normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion, Plantar Flexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): tender over lateral mallelolus Is there objective evidence of crepitus? [ ] Yes [X] No Left ankle ---------- [X] All Normal [ ] Abnormal or outside of normal range CONFIDENTIAL Page 17 of 43 [ ] Unable to test (please explain) [ ] Not indicated (please explain) Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Dorsiflexion, Plantar Flexion Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): tender over lateral mallelolus Is there objective evidence of crepitus? [ ] Yes [X] No b. Observed repetitive use Right ankle ----------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [X] Yes [ ] No Select all factors that cause this functional loss: Pain, Lack of enduance ROM after 3 repetitions: Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Left ankle ---------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [X] Yes [ ] No Select all factors that cause this functional loss: CONFIDENTIAL Page 18 of 43 Pain, Lack of endurance ROM after 3 repetitions: Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees c. Repeated use over time Right ankle ----------- Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms of range of motion? [X] Yes Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Left ankle [ ] No ---------- Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms of range of motion? [X] Yes Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees d. Flare-ups Right ankle ----------- Is the examination being conducted during a flare-up? [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X] Yes [ ] No [ ] Unable to say w/o mere speculation [X] Yes [ ] No CONFIDENTIAL Page 19 of 43 Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms or range of motion? [X] Yes Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees Left ankle ---------- Is the examination being conducted during a flare-up? [ ] No [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-up? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms of range of motion? [X] Yes Dorsiflexion (0-20): 0 to 20 degrees Plantar Flexion (0-45): 0 to 45 degrees e. Additional factors contributing to disability Right ankle [ ] No ----------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling, Instability of station, Disturbance of locomotion, Interference with standing Left ankle ---------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling, Instability of station, Disturbance of locomotion, Interference with standing 4. Muscle strength testing -------------------------- a. Muscle strength - rate strength according to the following scale 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength CONFIDENTIAL Page 20 of 43 Right ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes Left ankle: Rate Strength: Plantar Flexion: 5/5 Dorsiflexion: 5/5 Is there a reduction in muscle strength? [ ] Yes b. Does the Veteran have muscle atrophy? [ ] Yes c. Comments, if any: No response provided [X] No [X] No [X] No 5. Ankylosis ------------ Complete this section if Veteran has ankylosis of the ankle a. Indicate severity of ankylosis and side affected (check all that apply): Right side: [ ] In plantar flexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an eversion deformity [ ] In good weight-bearing position [ ] In good weight-bearing position [ ] In poor weight-bearing position [ ] In poor weight-bearing position [X] No ankylosis b. Comments, if any: No response provided 6. Joint stability ------------------ Right ankle Is ankle instability or dislocation suspected? [X] No ankylosis [ ] No [X] Yes If yes, complete the following: Anterior Drawer Test Is there laxity compared Left side: [ ] In plantar flexion [ ] In dorsiflexion [ ] With an abduction deformity [ ] With an inversion deformity [ ] With an eversion deformity CONFIDENTIAL Page 21 of 43 with opposite side? [ ] Yes [X] No [ ] Unable to test Talar Tilt Test Is there laxity compared with opposite side? Left ankle Is ankle instability or dislocation suspected? [ ] Yes [X] No [X] Yes If yes, complete the following: Anterior Drawer Test Is there laxity compared with opposite side? Talar Tilt Test Is there laxity compared with opposite side? [ ] Yes [ ] Yes [ ] Unable to test [ ] No [X] No [X] No 7. Additional comments ---------------------- Does the Veteran now have or has he or she ever had "shin splints", stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)? [X] Yes [ ] No If yes, indicate condition and complete the appropriate sections below: [X] Shin splints (medial tibial stress syndrome) Indicate side affected: [ ] Right [ ] Left [X] Both Does this condition affect ROM of ankle? [X] Yes (If "yes", complete ROM section of ankle on this DBQ) [ ] No Does this condition affect ROM of knee? [ ] Yes (If "yes", complete VA Form 21-0960M-9 Knee and Lower Leg Conditions) [X] No Describe current symptoms: pain in the shins with prolonged standding or walking [X] Achilles tendonitis or achilles tendon rupture Indicate side affected: [ ] Right [ ] Left [X] Both CONFIDENTIAL Page 22 of 43 Describe current symptoms: pain in the backs of the ankles shooting up the back of the shins 8. Surgical procedures ---------------------- No response provided 9. Other pertinent physical findings, complications conditions, signs, symptoms and scars ------------------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 10. Assistive devices --------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided 11. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's ankle condition, is there functional impairment of an extremity such that no effective functions remain other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 12. Diagnostic testing ---------------------- CONFIDENTIAL Page 23 of 43 a. Have imaging studies of the ankle been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 13. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: limits standing and walking prolonged, has to take frequent breaks or sit down 14. Remarks, if any ------------------- E-file reviewed. Veteran's ankle sprain is a diagnosable chronic multisymptom illness with a partially explained etiology that is less than likely as not related to an exposure event in Southwest Asia as symptoms are related to sprain not to an exposure event. **************************************************************************** Foot Conditions, including Flatfoot (Pes Planus) Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review CONFIDENTIAL Page 24 of 43 ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: pes planus b. Select diagnoses associated with the claimed condition(s): [X] Flat foot (pes planus) ICD code: 728.71 Side affected: Both Date of diagnosis: Right: 2003 Date of diagnosis: Left: 2003 c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? [X] Yes [ ] No [ ] N/A 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's foot condition (brief summary): Pes planus was noted on enlistment exam. She did not have pain in her eet when she first enlisted but the pain int he feet started in boot camp. She was treated with motrin and insoles which did not help. She contiues to have the foot pain now if she stands on them prolonged. She still takes motrin adn she soaks them and uses topical rubs. b. Does the Veteran report pain of the foot being evaluated on this DBQ? [X] Yes [ ] No CONFIDENTIAL Page 25 of 43 If yes, document the Veteran's description of pain in his or her own words: aching and cramping and sore c. Does the Veteran report that flare-ups impact the function of the foot? [X] Yes [ ] No If yes, document the Veteran's description of flare-ups in his or her own words: limtis prolonged standing and walking d. Does the Veteran report having any functional loss or functional impairment of the foot being evaluated on this DBQ (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: limits weight bearing 3. Flatfoot (pes planus) ------------------------ a. Does the Veteran have pain on use of the feet? [X] Yes If yes, indicate side affected: [ ] Right [ ] Left [X] Both If yes, is the pain accentuated on use? [X] Yes [ ] No [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both b. Does the Veteran have pain on manipulation of the feet? [X] Yes If yes, indicate side affected: [ ] Right [ ] Left [X] Both If yes, is the pain accentuated on manipulation? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both c. Is there indication of swelling on use? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both d. Does the Veteran have characteristic callouses? [ ] Yes [X] No e. Effects of use of arch supports, built-up shoes or orthotics: Tried But Remains Symptomatic ----------------------------- [ ] No Device Side Not Relieved: CONFIDENTIAL Page 26 of 43 [X] Arch Supports [ ] Right [ ] Left [X] Both f. Does the Veteran have extreme tenderness of plantar surfaces on one or both feet? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both Is the tenderness improved by orthopedic shoes or appliances? RIGHT - [ ] Yes [X] No [ ] N/A LEFT - [ ] Yes [X] No [ ] N/A g. Does the Veteran have decreased longitudinal arch height of one or both feet on weight-bearing? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both h. Is there objective evidence of marked deformity of one or both feet (pronation, abduction etc.)? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both i. Is there marked pronation of one or both feet? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both Is the condition improved by orthopedic shoes or appliances? RIGHT - [ ] Yes [X] No [ ] N/A LEFT - [ ] Yes [X] No [ ] N/A j. For one or both feet, does the weight-bearing line fall over or medial to the great toe? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both k. Is there a lower extremity deformity other than pes planus, causing alteration of the weight-bearing line? [ ] Yes [X] No l. Does the Veteran have "inward" bowing of the Achilles tendon (i.e., hindfoot valgus, with lateral deviation of the heel) of one or both feet? [X] Yes [ ] No If yes, indicate side affected: [ ] Right [ ] Left [X] Both m. Does the Veteran have marked inward displacement and severe spasm of the Achilles tendon (rigid hindfoot) on manipulation of one or both feet? [X] Yes [ ] No CONFIDENTIAL Page 27 of 43 If yes, indicate side affected: [ ] Right [ ] Left [X] Both Is the marked inward displacement and severe spasm of the Achilles tendon improved by orthopedic shoes or appliances? RIGHT - [ ] Yes [X] No [ ] N/A LEFT - [ ] Yes [X] No [ ] N/A n. Comments: No comments provided 4. Morton's neuroma (Morton's disease) and metatarsalgia -------------------------------------------------------- No response provided 5. Hammer toe ------------- No response provided 6. Hallux valgus ---------------- No response provided 7. Hallux rigidus ----------------- No response provided 8. Acquired pes cavus (clawfoot) -------------------------------- No response provided 9. Malunion or nonunion of tarsal or metatarsal bones ----------------------------------------------------- No response provided 10. Foot injuries and other conditions -------------------------------------- No response provided 11. Surgical procedures ----------------------- No response provided 12. Pain -------- RIGHT FOOT: Is there pain on physical exam? [X] Yes [ ] No If yes, (there is pain on physical exam), does the pain contribute to CONFIDENTIAL Page 28 of 43 functional loss? [X] Yes [ ] No (Further description of limitations requested in Section XIII below.) LEFT FOOT: Is there pain on physical exam? [X] Yes [ ] No If yes, (there is pain on physical exam), does the pain contribute to functional loss? [X] Yes [ ] No (Further description of limitations requested in Section XIII below.) 13. Functional loss and limitation of motion -------------------------------------------- a. Contributing factors of disability (check all that apply and indicate side affected): [X] Pain on movement Side affected: [ ] Right [ ] Left [X] Both [X] Pain on weight-bearing Side affected: [ ] Right [ ] Left [X] Both [X] Swelling Side affected: [ ] Right [ ] Left [X] Both [X] Disturbance of locomotion Side affected: [ ] Right [ ] Left [X] Both [X] Interference with standing Side affected: [ ] Right [ ] Left [X] Both [X] Lack of endurance Side affected: [ ] Right [ ] Left [X] Both Contributing factors of disability associated with limitation of motion: b. Is there pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when the foot is used repeatedly over a period of time? RIGHT FOOT: [X] Yes [ ] No If yes, (there is a functional loss due to pain, during flare-ups and/or when the joint is used repeatedly over a period of time) please CONFIDENTIAL Page 29 of 43 describe the functional loss: limits weight bearing LEFT FOOT: [X] Yes [ ] No If yes, (there is a functional loss due to pain, during flare-ups and/or when the joint is used repeatedly over a period of time) please describe the functional loss: limite weight bearing c. Is there any other functional loss during flare-ups or when the foot is used repeatedly over a period of time? RIGHT FOOT: [ ] Yes [X] No LEFT FOOT: [ ] Yes [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No c. Comments: No comments provided 15. Assistive devices --------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 16. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's foot condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the CONFIDENTIAL Page 30 of 43 upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 17. Diagnostic testing ---------------------- a. Have imaging studies of the foot been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed condition: No response provided 18. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: limits prologned walking andd standing 19. Remarks, if any: -------------------- E-file reviewed. Veteran's pes planus is a diagnosable chronic multisymptom illness with a partially explained etiology that is less than likely as not related to an exposure event in Southwest Asia as pes planus was present on entrance exam and symptoms started in boot camp before any exposure event in Southwest Asia. **************************************************************************** CONFIDENTIAL Page 31 of 43 Gynecological Conditions Disability Benefits Questionnaire Name of patient/Vetera Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ Does the Veteran now have or has she ever had a gynecological condition? Yes Diagnosis #1: Vaginitis ICD code: 616.1 Date of diagnosis: 2004 2. Medical history ------------------ Describe the history (including cause, onset and course) of each of the Veteran's gynecological conditions: Veteran was sexually assaulted in boot camp and the vaginits started after that incident. She was treated for the vaginits. She has reoccurring BV now and gets it after her cycle. She also reports she gets a yeast infection before her cycle each month. 3. Symptoms ----------- Does the Veteran currently have symptoms related to a gynecological condition, including any diseases, injuries or adhesions of the female reproductive organs? Yes CONFIDENTIAL Page 32 of 43 If yes, indicate current symptoms, including frequency and severity of pain, if any: (check all that apply) [X] Mild pain: Intermittent pain [X] Other signs and/or symptoms describe and indicate condition(s) causing them: vaginal discharge and odor and itching caused by candidiasis and bacteria 4. Treatment ------------ a. Has the Veteran had treatment for symptoms/findings for any diseases, injuries and/or adhesions of the reproductive organs? Yes If yes, specify condition(s), organ(s) affected, and treatment: treated with diflucan and flagyl Date of treatment: recurrent b. Does the Veteran currently require treatment or medications [for symptoms?] related to reproductive tract conditions? Yes If yes, list current treatment/medications and the reproductive organ condition(s) being treated: ongoing diflucan and flagyl treatments when infections occur c. If yes, indicate effectiveness of treatment in controlling symptoms: [X] Symptoms do not require continuous treatment for the following organ/condition: [X] Conditions of the vulva [X] Conditions of the vagina 5. Conditions of the vulva -------------------------- Has the Veteran been diagnosed with any diseases, injuries or other conditions of the vulva (to include vulvovaginitis)? Yes If yes, describe: vulvovaginitis causes itching and burning of the vulva. Treated with diflucan 6. Conditions of the vagina --------------------------- Has the Veteran been diagnosed with any diseases, injuries or other conditions of the vagina? Yes If yes, describe: vaginitis (candida and BV0 treated with diflucan and flagyl 7. Conditions of the cervix --------------------------- Has the Veteran been diagnosed with any diseases, injuries, adhesions or CONFIDENTIAL Page 33 of 43 other conditions of the cervix? No 8. Conditions of the uterus --------------------------- a. Has the Veteran been diagnosed with any diseases, injuries, adhesions or other conditions of the uterus? No b. Has the Veteran had a hysterectomy? No c. Does the Veteran have uterine prolapse? No d. Does the Veteran have uterine fibroids, enlargement of the uterus and/or displacement of the uterus? No e. Has the Veteran been diagnosed with any other diseases, injuries, adhesions or other conditions of the uterus? No 9. Conditions of the Fallopian tubes ------------------------------------ Has the Veteran been diagnosed with any diseases, injuries, adhesions or other conditions of the Fallopian tubes (to include pelvic inflammatory disease)? No 10. Conditions of the ovaries ----------------------------- a. Has the Veteran undergone menopause? No b. Has the Veteran undergone partial or complete oophorectomy? No c. Does the Veteran have evidence of complete atrophy of 1 or both ovaries? No d. Has the Veteran been diagnosed with any other diseases, injuries, adhesions and/or other conditions of the ovaries? Yes If yes, describe: had ovarian cysts when she was younger but none recently 11. Incontinence ---------------- Does the Veteran have urinary incontinence/leakage? Yes If yes, is the urinary incontinence/leakage due to a gynecologic condition? Yes If yes, condition causing it: stress incontinence If yes, check all that apply: [X] Does not require/does not use absorbent material [X] Stress incontinence CONFIDENTIAL Page 34 of 43 12. Fistulae ------------ a. Does the Veteran have a rectovaginal fistula? No b. Does the Veteran have a urethrovaginal fistula? None 13. Endometriosis ----------------- Has the Veteran been diagnosed with endometriosis? No 14. Complications and residuals of pregnancy or other gynecologic procedures ---------------------------------------------------------------------------- a. Has the Veteran had any surgical complications of pregnancy? No b. Has the Veteran had any other complications resulting from obstetrical or gynecologic conditions or procedures? No 15. Tumors and neoplasms ------------------------ a. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section? No b. Is the neoplasm No response provided. c. Does the Veteran currently have any residual conditions or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above? No response provided. d. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in the Diagnosis section, describe using the above format: No response provided. 16. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? No c. Comments, if any: CONFIDENTIAL Page 35 of 43 No response provided. 17. Diagnostic testing ---------------------- a. Has the Veteran had laparoscopy? No b. Has the Veteran been diagnosed with anemia? No c. Has the Veteran had any other diagnostic testing and if so, are there significant findings and/or results? No 18. Functional impact --------------------- Does the Veteran's gynecological condition(s) impact her ability to work? No 19. Remarks, if any: -------------------- E-file reviewed. Veteran's vaginitis is a diagnosable chronic multisymptom illness with a partially explained etiology that is less than likely as not related to an exposure event in Southwest Asia as symptoms are from bacteria overgrowth and not related to exposure events. **************************************************************************** Knee and Lower Leg Conditions Disability Benefits Questionnaire Name of patient/Veteran: Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review CONFIDENTIAL Page 36 of 43 --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 1. Diagnosis ------------ a. List the claimed condition(s) that pertain to this DBQ: knee dislocation b. Select diagnoses associated with the claimed condition(s) (Check all that apply): [X] Recurrent patellar dislocation Side affected: [ ] Right [X] Left [ ] Both ICD Code: 836 Date of diagnosis: Left 2010 c. Comments (if any): No response provided d. Was an opinion requested about this condition (internal VA only)? [ ] Yes [X] No [ ] N/A 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's knee and/or lower leg condition (brief summary): Veteran denies any spoecific injury while in service. She reports left knee started dislocation after military service. She treats it with wearing a brace and ice and heat. b. Does the Veteran report flare-ups of the knee and/or lower leg? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: locks up and a shooting pain c. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this DBQ, including but not limited to repeated use over time? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: limits standing and bending down and lifting CONFIDENTIAL Page 37 of 43 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion Left Knee --------- [X] All normal [ ] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Flexion, Extension Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): ttp behind knee Is there objective evidence of crepitus? [ ] Yes b. Observed repetitive use [X] No Left Knee --------- Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional functional loss or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Left Knee --------- Is the Veteran being examined immediately after repetitive use over time? [X] Yes [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: CONFIDENTIAL Page 38 of 43 Pain, Lack of endurance Able to describe in terms of range of motion: [X] Yes Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees d. Flare-ups Left Knee --------- Is the exam being conducted during a flare-up? [X] Yes [ ] No [ ] No Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [X] Yes [ ] No [ ] Unable to say w/o mere speculation Select all factors that cause this functional loss: Pain, Lack of endurance Able to describe in terms of range of motion: [X] Yes Flexion (0 to 140): 0 to 140 degrees Extension (140 to 0): 140 to 0 degrees e. Additional factors contributing to disability [ ] No Left Knee --------- In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Swelling, Instability of station, Disturbance of locomotion, Interference with standing 4. Muscle strength testing -------------------------- a. Muscle strength - Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Rate Strength: 5/5 Left Knee: Flexion: Extension: Is there a reduction in muscle strength? b. Does the Veteran have muscle atrophy? [ ] Yes [X] No c. Comments, if any: No response provided 5/5 [ ] Yes [X] No CONFIDENTIAL Page 39 of 43 5. Ankylosis ------------ Complete this section if the Veteran has ankylosis of the knee and/or lower leg. a. Indicate severity of ankylosis and side affected (check all that apply): Left Side: [ ] Favorable angle in full extension or in slight flexion between 0 and 10 degrees [ ] In flexion between 10 and 20 degrees [ ] In flexion between 20 and 45 degrees [ ] Extremely unfavorable, in flexion at an angle of 45 degrees or more [X] No ankylosis b. Indicate angle of ankylosis in degrees: No response provided c. Comments, if any: No response provided 6. Joint stability tests ------------------------ a. Is there a history of recurrent subluxation? Left: [ ] None [X] Slight [ ] Moderate b. Is there a history of lateral instability? Left: [X] None [ ] Slight [ ] Moderate c. Is there a history of recurrent effusion? [ ] Yes [X] No d. Performance of joint stability testing Left Knee: Was joint stability testing performed? [X] Yes [ ] No [ ] Not indicated [ ] Indicated, but not able to perform [ ] Severe [ ] Severe If joint stability testing was performed is there joint instability? [ ] Yes [X] No If yes (joint stability testing was performed), complete the section CONFIDENTIAL Page 40 of 43 below: - Anterior instability (Lachman test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Posterior instability (Posterior drawer test) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) - Lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion) [X] Normal [ ] 1+ (0-5 millimeters) [ ] 2+ (5-10 millimeters) [ ] 3+ (10-15 millimeters) e. Comments, if any: No response provided 7. Additional conditions ------------------------ a. Does the Veteran now have or has he or she ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment? [X] Yes [ ] No If yes, indicate condition and complete the appropriate sections below. [X] "Shin splints" (medial tibial stress syndrome) Indicate side affected: [ ] Right [ ] Left [X] Both Does this condition affect ROM of knee? [ ] Yes [X] No Does this condition affect ROM of ankle? [X] Yes [ ] No (If yes, complete VA form 21-0960M-2 Ankle Conditions to document ROM of ankle.) Describe current symptoms: pain in shins with prolonged walking or standing CONFIDENTIAL Page 41 of 43 b. Comments, if any: No response provided 8. Meniscal conditions ---------------------- a. Does the Veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition? [ ] Yes [X] No b. For all checked boxes above, describe: No response provided 9. Surgical procedures ---------------------- No response provided 10. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ------------------------------------------------------------------------ a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [X] Yes [ ] No If yes, describe (brief summary): popping noted with flexion and extension testing b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided 11. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [X] Yes [ ] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): Assistive Device: ----------------- [X] Brace(s) Frequency of use: ----------------- [X] Occasional [ ] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: CONFIDENTIAL Page 42 of 43 No response provided 12. Remaining effective function of the extremities --------------------------------------------------- Due to the Veteran's knee and/or lower leg condition(s), is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 13. Diagnostic testing ---------------------- a. Have imaging studies of the knee been performed and are the results available? [ ] Yes [X] No b. Are there any other significant diagnostic test findings and/or results? [ ] Yes [X] No c. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions: No response provided 14. Functional impact --------------------- Regardless of the Veteran's current employment status, do the condition(s) listed in the Diagnosis Section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)? [X] Yes [ ] No If yes, describe the functional impact of each condition, providing one or more examples: limits bending, lifting, standing and walking 15. Remarks, if any: -------------------- E-file reviewed. Veteran does have recurrent knee dislocation that is a is a diagnosable chronic multisymptom illness with a partially explained etiology that is less than likely as not related to an exposure event in Southwest Asia as symptoms did not start until after military service and she had no documented injury in Iraq and exposure would not cause these symptoms.
  5. Okay, so this is going to be hard to believe for anyone reading this, and it's fine if you don't because it happened to me and I'm still having hard time believing it. Back in 2014 I got into an argument with a VA dermatology doctor about putting me on Accutaine/ Isotretinoin for Cystic Acne. I showed her that I hadn't finished the treatment as a civilian due to entering the service and the same thing happened upon getting out, but she wouldn't put me on it and claimed no sane doctor would. I went to a civilian dermatologist and she recommended I be put on the treatment on the first visit. Furthermore, the civilian doctor said I would be a "perfect candidate" for the treatment. I brought this back to the VA dermatologist and she was furious. She stuck to her decision, and brought in a fellow dermatologist to back her up, and man she brought in identified himself as a dermatologist and backed her up and that was about it for that situation... Almost two years later, this past March 7th, I had an appointment for a GERD disability claim, and a lower back pain disability claim. The examiner was none other then the dermatologist my psycho dermatologist doctor brought in to back her up. It took me a while to remember where I had seen him before, but halfway through the exam it hit me. However, he didn't recognize me. He also didn't seem to know anything about the human body because when I tried to explain to him that a bad knee day equals a bad lower back day he tried to tell me this did not matter. This was quite shocking and disturbing to hear because my chiropractor has told me that the two issues are connected, and so did my knee surgeon. Then last week I went to pick-up a buddy of mine at the ER due to a really bad sinus infection, and when I went to the front desk to get my friend I see the same guy who was my C&P examiner and who supposedly was a dermatologist treating patients in the ER!! What the hell is going on here? Is this dude even a doctor at all? Has anyone experienced such a thing?
  6. Hello all! I'm in the process of a claim for blood disorders. I'm actually in PFN stage as of yesterday so I've been a little bit nervous! The rating criteria state that if my levels are between 30-70, the rating will be 70% and if levels are between 70-100, the rating will be 30%. Over the past 2 years, my levels fell anywhere between 30-100, and over the past 6 months, my levels were under 70. My question is, will the VA take past levels into consideration or will my rating be based off of what my levels were at the time I had blood tests during my C&P exam?
  7. Well first off, SHOUT out to BUCK!!!! Thank you for the advice to go and get copies of my C&P exams from the BVA office at the VA Dallas Hospital! It worked like a charm! BTW these C&P exams were done at a QTC facility! So with that being said, I need your input on this C&P exam. I applied for an increase to my Left Ankle Synovitis 10% - totally loss on this and would love feedback! Please see attached the report. C&P left ankle increase.pdf
  8. Hi brothers and sisters, I'm new to this blog I have been reading a lot of information. But I have a specific question about my situation. When I was rated last time I had 10% for my back, 10% for my knees so I was at 30%. Fast forward till now, in December I filed for an increase of my back issues because I have a sciatica and its really hindering my way of life and that of my family. In January I was given a C&P Exam. The doctor that did it, did ask me question on how was I feeling and then he proceeded to do the tests. When he did the forward flexion he asked me is that the farthest you can bent and I said yes (he was asking like not believing me of course). I thought he had actually used his Brom Tool and also when I did the side lateral flexion he didn't even measure my left side because the exam table was on his way. Well I thought nothing of it when he was filling out the DBQ for my back he didn't ask me that many questions and he was like don't worry I'm going to help you (sure buddy). So in February a month later I got my ratings and I was like OK that was pretty fast. When I received it they only raised it to 20% I went to my Benefits website and I saw that the doctor had put that I was able to flex to 40% which is a lie of course and he said I don't loose any power without repetition, but he never did any repetition test either. And other mistakes and answers that I didn't even give him. So my question is, I did Physical Therapy for the VA in April 2015, for 3 months and it was at an outside location not the VA. So I asked for the records that were sent to the VA and it didn't have all the notes from the Physical Therapist. So after I received my ratings and the letter, on the letter it said that they had seen all my medical records from the VA and my new MRI and all this info that I gave them. But the notes of the PT aren't in there, so I went and requested a copy from the PT that I went to and to my amazement I saw that when I went there the first time he did my measurements and he put it at 20% and when I left after 3 months he was able to help me to get it 22% according to the CFR if I have forward flexion of 30% or less I should be at 40%. Is this good enough evidence to send in a NOD? And can I just tell them on the NOD the information that I found from the PT, and how the test was conducted by the doctor that did the Exam? I believe a review by a DRO of the whole case and paperwork would grant me my 40% correct or what do you guy/gals think? I mean my back is getting worse by the years not better so how can the VA think that from 20% flex it can go to 40% when I haven't even had a permanent doctor with the VA for 2 years. Thank You, Oscar
  9. Okay so I talked to a lady I know that helps veterans and she was able to read me what the C&P exam over the phone. She is not able to send me a copy so I will do as Buck advised and go to the VA hospital and get copies of them from the VBA office. This is exam was for my L ankle synovitis 10% increase on my FDC claim. "Diagnoses from VA originally L ankle synovitis has changed - new and separate diagnoses. Worsening symptoms of pain with rapid progression since right foot was injured. Weight and pressure to L since using knee scooter and using L to propel. Tendonitis & Tendinopathy of Peroneus Brevis." She noted constant pain and swelling - ROM Left dorsiflexion is 0 to 15; Plantar flexation is 0 to 25 Functional loss YES She noted Left instability of station; disturbance of locomotion; and pain/weakness If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. She indicated all the way back to 1991 while in the service and reviewed all previous records from service time to current to include, SMR's; DBQ's submitted in 2013 and all my VA medical records with my current podiatrist since 2014 to present. She noted - functional impact - regardless of veteran's current employment - effects standing, weight bearing, and walking she checked YES The doctor noted unable to do ROM due to Non-weight bearing of the right foot and she noted the scars and measurements as well. She noted that I had multiple injuries to Left ankle All C&P exams according to the Ebennies calendar has been acknowledged as received as of today so they are in the VA hands now... This all I got from a phone call thoughts????
  10. Just had my C&P last week. And, I've been trying to figure out if I will get the compensation benefits and at what percentage?..I was hoping some of my service family could help me with..Appreciate any input you guys or girls can give me. Thanks!! Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: Taylor, David G. 0507 SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: 309.89 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Other Trauma- and Stressor- Related Disorder ICD code: F43.8 Comments, if any: This is the DSM-5 diagnosis which applies when symptoms characteristic of a trauma- and stressor-related disorder cause clinically significant distress or impairment, but do not meet the full criteria for any other specific disorders within this category. In Mr. Taylor's case, criteria are met for categories A. (stressor), B. (intrusive symptoms), and C. (avoidance symptoms), but not catagories D. (Negative alterations in cognition and mood) and E. (Marked alterations in arousal and reactivity). Mental Disorder Diagnosis #2: Unspecified Depressive Disorder ICD code: F32.9 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes [ ] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [X] Yes [ ] No [ ] Not applicable (N/A) If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: Mr. Taylor's Other Specified Trauma- and Stressor- Related Disorder includes situational symptoms which are activated by situations like thunderstorms. These symptoms are reported to include intrusive thoughts/fears/memories and accompanying states of anxiety. Mr. Taylor makes efforts to avoid encountering triggering stimuli. The Unspecified Depressive Disorder includes symptoms of sad and depressed moods, decreased energy and motivation, interpersonal withdrawal, feelings of hopelessness, and anxious distress. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [X] Yes [ ] No [ ] No other mental disorder has been diagnosed If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: The symptoms related to Mr. Taylor's Other Specified Trauma- and Stressor- Related Disorder are situationally circumscribed and seem to be mild or transient in nature. Symptoms of the Unspecified Depressive Disorder are more pervasive, resulting in occasionally diminished social and occupational functioning. c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [X] Military service treatment records [X] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [X] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Mr. Taylor was born and raised in Buffalo, NY. Family consisted of his mother and a brother five years older. Mr. Taylor's father was not involved in his upbringing. Growing up, "We weren't rich... single mom... towards (my) teenaged years she got addicted to some things... got pretty bad... brother was older, so I was kind of there by myself a lot." "I had a godfather that kind of watched me when my mom was working... He was there, which is more than what I could say about my dad..." Father had 15 children- "You can see why he wasn't around... came around to high school graduation... boot camp graduation... I forgave him... just the type of person he is... I have all these other siblings... call me when they need some money... Only time I talk to them is when I go visit... got a little sister who will call me once in a blue moon..." Relationship with his brother- "We're working on it... He was a little abusive... beating me up... one time I had to come at him with a knife... I was always doing the chores... wasn't really the best brother to have... Think he was probably a littl e jealous... He always had problems in school... I was kind of the smart one... He apologized to me... We're working on it..." First marriage- 1995-1997. From that relationship, "I had a daughter and a son (both are currently in Buffalo), same mom..." "My daughter, she's 20... pregnant now... with a man that's older than I am... I think it's because I wasn't there... looking for a father figure (Mr. Taylor is visibly, audibly sad, no longer making eye contact)... My daughter, that's awreck... She's staying over there with the guy... He's trying to control her... I talked to her about stuff, but kind of late, like 16, 17... Her mom and her got into it and her mom said she had to go... but too young to go... I just want to be there for her when she needs someone... If I was there, it could have been a little different..." "My son, I'm still working on him... I think he's a little mad... thinks I abandoned him... wasn't my choice... couldn't financially help him... I flew him down a couple summers ago... apologized to him for not being there... told him my thoughts... I got to be honest with myself, I could have done more for him..." "I was married (second) for about seven, eight years... two kids in that marriage... I was unfaithful, but she kind of forgave me... but I think that was more a way to get out.. I don't think I was really.. I get in so many situations I'm not comfortable... I'm not maybe the marriage type... getting married for no reason... I just left..." Current marriage of three years- "Terrible... I don't know if it's me... reason I'm here is maybe 50%... I think I moved too fast once again... When I left my first marriage, I was supposed to work on myself... I think it was more just having somebody there... She's kind of verbally abusive, and I think I allow it because... I can take a lot..." "I don't want to be a third time loser... but I think I need to be by myself... same thing over and over..." "She (current wife) thinks I'm just around now because it's comfortable... If I could afford to move, I'd have been gone... That's true... I bit off more than I could chew.... worst thing that could have happened to me... wrong relationship for me... I need to go, but I don't know how..." "My second kids... When they come over my house... feeling guilty because I left them... If I was there, they'd be living a little bit better... a little bit of order... I try to make sure when they come and see me that everything is good... got clothes... do things with them..." His current wife gets mad because they don't have more responsibilities when they visit. Friends- "I have friends... wife kind of chased them off... Now I'm embarrassed to even go... They know... certain changes... She throws temper tantrums... doesn't really have no respect for nobody..." b. Relevant Occupational and Educational history (pre-military, military, and post-military): School- "Very well... honor roll... played basketball." Pre-service work at McDonald's. Marine Corps- 1995-1999- Administrative Clerk- No deployments. Honorable discharge. "The reason why I got in... I had a daughter on the way when I was in high school... early entry program... didn't work out so well... She (wife) broke up... She was gonna go to school and come back... didn't hear from her for a while... back with her old boyfriend... caused my issues in the service... I told my commanding officer I needed to go home... try to save my marriage... I came back and they shipped me to another office... Headquarters Battalion... They were more focused on the job than some young guy focused on trying to save his marriage..." After the Marines, "A lot of call-center the first couple years... kind of moved down here because there wasn't a lot of good jobs where I'm from... I got laid off about a year ago... help desk... Carolinas' Associated General Contractors... about seven or eight years..." Currently, "I'm working at Lending Tree in Ballantyne now... going good... I'm always able to separate (work life)... from my personal life..." c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Mr. Taylor says he took anger management classes during the service, following an altercation with his wife. No indication of any other mental health problems observed in STR, nor in military separation exam- June 8, 1999. Denies any mental health services before or after the military. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): During the service, "I got some anger management classes... Me and my ex-wife had got into it.. she kind of hit me first.. reactionary thing... I hit her back... I did get arrested for that think with my first wife... got restrictions for a week or two... money taken away..." Other disciplinary action, "Here and there... I'm not good at relationships I don't think... kind of got in trouble sleeping around with a... married woman... some other rules things... over-sleeping because I was drunk maybe a couple times..." Thinks he had two or three Article 15s. "I did get caught shop-lifting... When I was young... didn't have money to buy things... (in the service) video game card... got like 30 days restriction... like $400 in pay... maybe why I never got promoted beyond E-3... Most of the things happened during the first two years... kind of settled down after that." e. Relevant Substance abuse history (pre-military, military, and post-military): Alcohol- "Usually I'm just a social drinker... lately... kind of depressed... things ain't working out like they should have... expected more of myself... I might make two or three (drinks), maybe three, four times a week..." Sometimes more. No history of alcohol treatment. No history of illicit substances. f. Other, if any: Sleep- "I guess it depends... lately either I can sleep good, real deep... or I have... since I applied for this... sleep more off and on because I'm thinking about it... some periods I might have like restless leg syndrome... wife tells me... in and out of it..." "I try to work out now... try to help me sleep a little better... This bad relationship I'm in though, don't help me with my sleep..." Mr. Taylor says he gets "a good five" hours of sleep, "Then I toss and turn... had a surgery on my thumb... bulging disc in my neck... muscle relaxers... help me go to sleep..." Depression- "I've been depressed for a while... kind of live with it... I do have thoughts of maybe, you know..." Denies suicidal intent or plan. Wouldn't act on it because of his children. "I think I'm just hard on myself... The women, I don't really have emotional attachment with... my kids, I love my kids... feel like I've failed them... guilt... probably don't do what I need to do to handle it right..." Talks about his son acting out, being disrespectful to his mother, with Mr. Taylor feeling guilty/responsible for it. "If I was there, I know that wouldn't be going on." "My confidence in myself... kind of mumbling... I lost it somehow... It's embarrassing... Everything pretty much... I think my mom had more hope for me... kind of let myself and my kids down... especially my older kids..." Anger, "I can keep it in check, cause if I don't keep it in check, I don't know where it will go... That's the reason I don't discipline my kids... one time I did it... ended up (going too hard)... that's why I don't..." Anxiety, "I think I'm... I can tell by how my nails look, how I'm doing lately... I swear it has something to do with losing my hair... I kind of go in kind of a shell too... There's kind of a compulsive thing I do... I always got a remote in my hand... constantly going back and forth (does some numerical patterns with buttons/symmetry). "If it's raining... lightning... If I see that (memory of reported stressor)... even in the car... Even though when the lightning struck, we weren't near a tree... lightning hit the ground... I always had a wariness of... lightning... staying where I'm at, or make sure if I'm getting anywhere, I don't see no puddles of water... or passing by trees or metal... I know it happens... I was right there... I'm staying there until it at least slows down..." "Ever since I started coming here, I keep replaying it in my mind... wonder if it has anything to do with what's going on..." 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: "What they said and what happened are two different things... storms... rifle range... lightning hit the surrounding tree line... I'm like... 'That's real close... don't know why we were still there.'... As we were leaving... two formations... guys (other group) right behind me... I was in the back of mine... Drill sergeant was like, 'Cover your rifles with your ponchos.'... We were doing that... All the sudden... blue light... no sound... feel this heat on the back of my neck... several of us got down... As I turn around... see several guys down on the ground... Drill instructor is running up... eyes out of his head... 'Everybody get up to the... shelter!'... This one guy... just down... all this happened in probably no more than ten seconds... That heat... and you could smell it, like electrical burn... 'til I hear the boom, then I recognized what it was... My ears was ringing... One of the guys... He had died... hit him first, and came out and hit the people closest to him... We was in boot camp... didn't tell us anything... We went to his funeral... after that, we didn't do but ten or fifteen percent of the stuff... because it was raining a lot... lightning... We didn't do it after that... He could have been alive if we'd have left ten minutes earlier..." Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [ ] Yes [X] No If no, explain: Mr. Taylor was witness to another man being killed by a lightning strike during training. Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. Do NOT 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 and Statistical 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: [X] Witnessing, in person, the traumatic event(s) as they occurred to others Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] 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 the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, 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: No response provided. 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: No response provided. Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Chronic sleep impairment 6. Behavioral Observations -------------------------- Mr. Taylor arrived about 15 minutes early for his appointment. He was neatly and casually dressed. No abnormalities of gate or posture were noted. He was cooperative with the interview process and made good eye contact. Mr. Taylor was fully oriented. Speech was clear and coherent, quiet at times. Mood was somewhat depressed. Affective expression was mild, congruent, sad at times. Thought process was logical and goal-directed. Thought content was relevant and with adequate detail. Gross concentration and memory were adequate. Insight and judgment are in tact. There was no evidence of perceptual disturbance. There was no evidence of thought disorder or hallucinations. Mr. Taylor relates that he has thought about suicide, but denies any intent or plan. Homicidal ideation is denied. 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- Prior to beginning the interview, the undersigned examiner informed the veteran of the purpose of the evaluation, the role of the undersigned examiner, and the limits of confidentiality. The veteran indicated understanding of the aforementioned information. Per VA Memorandum titled Information Bulletin: Implementation Guidance for the Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) use in Compensation and Pension Examinations, dated December 16, 2013, this examination was conducted using DSM-5 criteria. Of note, the DSM-5 no longer requires computation of a GAF score. Per 2507: "Please indicate in exam report the stressor(s) claimed by the veteran upon which a diagnosis of PTSD is based. **If a diagnosis other than PTSD is rendered, please state if that psychiatric condition is at least as likely as not (50 percent or greater probability) linked to the conceded stressor." Examiner's Response: Mr. Taylor does not meet DSM-5 criteria for a diagnosis of PTSD. However, he does currently meet criteria for Other Specified Trauma- and Stressor- Related Disorder. This includes situational symptoms including intrusive thoughts/fears/memories of the stressor event, with accompanying states of anxiety, which are triggered by situations like thunderstorms. Mr. Taylor makes efforts to avoid encountering triggering events. The Unspecified Depressive Disorder includes symptoms of sad and depressed moods, decreased energy and motivation, interpersonal withdrawal, feelings of hopelessness, and anxious distress. The symptoms related to Mr. Taylor's Other Specified Trauma- and Stressor- Related Disorder are situationally circumscribed and seem to be mild or transient in nature. Symptoms of the Unspecified Depressive Disorder are more pervasive, resulting in occasionally diminished social and occupational functioning. It is at least as likely as not (50 percent or greater probability) that Mr. Taylor's currently diagnosed Other Specified Trauma- and Stressor- Related Disorder is due to his having been witness to the lightning strike killing a fellow Marine during training. The reported stressor is sufficient for the potential development of a trauma- or stressor-related disorder. The symptoms of intrusive thoughts/fears/memories of the stressor, accompanying states of anxiety, and efforts to avoid triggers to memory of the stressor are meaningfully related to the stressor itself. It is less likely as not (less than 50 percent probability) that Mr. Taylor's currently diagnosed Unspecified Depressive Disorder is due to the lightning strike killing a fellow Marine during training. Mr. Taylor's problems with depression seem more likely due to historical and current difficulties with significant other relationships, difficulties and regret in his relationships with his children, and perhaps aspects of adverse circumstances during childhood.
  11. I am curious if this has happened to anyone? Has anyone ever gone for a C&P exam for a specific claim and been awarded additional s/c for other contentions not filed for? The reason I ask this, is b/c my exam yesterday for increase to my L ankle, the doctor made a lot of notes to include measurements of my scars (not requested) as well as other notes regarding my foot and toe and my other foot (which is in appeal status). Thoughts?
  12. I had two C&P exams today, and one of them was for an increase for my Left ankle. During the examination she measured my scars on my left ankle, left foot toe and my right foot scar. Any idea why?
  13. Well with all that is going on for me....With my DRO hearing at the end of the month, I now have my C&P exams scheduled for tomorrow that pertain to my FDC that I filed on 1/12/16. I got the packet in the mail last week and I have gotten all my evidence ready for each exam. My one exam is for an increase to my Left Ankle Synovitis. I have a great letter from my podiatrist to back me up doctor letter_Redacted.pdf as well as I have all my medical records from the time I was S/C to current. Not sure if the examiner has them or not so I am bringing them. I plan to bring my Osteogenesis stimulator with me. I am sure I will look a hot mess rolling up on my knee bike with my right foot in a boot from the fall. My FDC also includes a request for 100% temporary convalescence for the past surgery to my right foot. Since it's not S/C (hence the DRO hearing coming up addresses this issue), I requested to be compensated based on the fact that my Left Ankle caused the fall (see letter from doctor I attached). I also have an evaluation for PTSD/MST So I have two C&P exams tomorrow, one for the ankle and the other for MH.....
  14. My question is in regards to a recently completed C&P exam I had taken for MH. I am quite worried about the statements made by the examiner and a few other sections as well. I have tried to highlight the sections that worried me I am not sure if I had missed anything of importance. Normally I would take this issue up with my VSO but she is out sick. I do not know who else or where else to turn to for information about this. I am most worried about the statements made by the examiner in the final paragraph. I did as I was told by my VSO and others in the VA and are assisting me currently in matters of mental health. That was be honest and it will all be okay. Well turns out it might not be okay and I was completely honest with this examiner!!! Date/Time: 21 Jan 2016 @ 1330 Note Title: C&P MENTAL DISORDER Location: Chalmers P Wylie VA Outpatnt Signed By: Co-signed By: Date/Time Signed: 21 Jan 2016 @ 1650 ------------------------------------------------------------------------- LOCAL TITLE: C&P MENTAL DISORDER STANDARD TITLE: MENTAL HEALTH C & P EXAMINATION CONSULT DATE OF NOTE: JAN 21, 2016@13:30 ENTRY DATE: JAN 21, 2016@16:50:27 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED *** C&P MENTAL DISORDER Has ADDENDA *** Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [ ] Yes [ ] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Diagnosis Deferred Comments, if any: The veteran was asked to be evaluated for PTSD, the stressor has been conceded as he has been awarded the Combat Infantry Badge. The diagnosis is deferred as the examiner is unable to offer a specific diagnosis with any level of scientific certainty. The veteran was administered the MMPI-2-RF, although it appears he understood and responded to the items in a consistent manner, the remainder of the profile is not able to be interpreted due to an over-reporting of symptomatology that is not common even in individuals with known severe psychopathology. There are a number of potential reasons for this profile to include it being a "plea for help", it may be a phenomenologic style to over report and to be traumatized (this pattern is frequently seen in Dependent and Histrionic Personality Disorders and Depressive Mood Disorders) or the individual is trying to look worse than they are for some secondary reason. Unfortunately it is impossible to determine the reason behind this pattern of responding in this case without resorting to speculation. His service treatment records suggest that he did not report PTSD symptoms while in the military. While he has been diagnosed and treated recently for PTSD, the requirements for a clinical diagnosis differ from the requirements for an independent/forensic evaluation. In the latter situation the examiner is required to consider other factors for an individual's complaints while a clinician takes their patient's report as being valid. Please note that the 2507 requested that the examiner complete both the mental disorder and Initial PTSD DBQ's, only the Initial PTSD DBQ will be completed as completing the Mental Disorder DBQ is redundant. In regards to the question as whether or not the veteran's sexual dysfunction is at least as likely as not approximately due to or the result of PTSD, while the veteran reports he has some difficulties sexually due to his prescriptions the veteran remains sexually active and furthermore there are other physical conditions as well as medications that may be negatively impacting his sexual dysfunction, as such the final decision is deferred to a physician. In regards to question whether the veteran's insomnia is at least as likely as not approximately due to are the result of PTSD; this would be a redundant opinion as chronic sleep difficulties are a symptom of PTSD (and depression), they are not a separate diagnosis/syndrome. Mental Disorder Diagnosis #2: Cluster B traits Mental Disorder Diagnosis #3: Alcohol Use Disorder - in self-reported remission b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): see medical records 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? No response provided. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [ ] No [X] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) No response provided. b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? No response provided. c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [ ] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: The veteran's electronic medical records (CPRS & VistAWeb) were reviewed. The veteran was referred for a compensation and pension examination. The veteran was informed verbally of the nature and purpose of the examination and confidentiality limits. He appeared to have a basic understanding of the purpose of the examination and confidentiality limits. He was provided with a chance to ask questions about the evaluation procedures. All questions were answered to reasonable satisfaction or referred to other resources. He was informed that this examiner is not his treating clinician or the legal determiner of compensation or pension benefits. Instead, he was informed that this examiner is an independent provider of clinical information and expertise to assist those who review and make legal compensation and pension claim decisions and would not be participating in his healthcare. He was given information about the Veteran's 24 hour Crisis Line. The veteran indicated understanding of these terms and explicitly and freely consented to the evaluation. The judgments of symptoms and opinions in this evaluation report are offered to a reasonable degree of psychological certainty and are only based upon the information available at the time of the evaluation. The DSM 5 criteria have been considered in this evaluation. This report was dictated using Dragon Naturally Speaking dictation software, the report has been proofread however due to time constraints there still may be some typographical errors due to the nature of the dictation software. b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): The veteran is a 28-year-old single male, he is not currently in a relationship. He currently lives in a homeless shelter, he has one roommate in addition to 6 other veterans living in the house. He has no children. [Later during the interview the veteran reported having met a woman using a smart phone dating app (Tinder), although they are not in a relationship they still get together occasionally for sex]. The veteran is the younger of 2 children, he does not get along with his sister saying "she had a rough time with drugs." The veteran says that he does not like "the way she treats my mother and my nephew." Apparently one of her 3 children is living with the veteran's mother and this causes difficulties in that relationship as well as the veteran's relationship with his sister. The veteran says his parents were never married saying "my father left prior to my birth." He would continue to see his father for a couple of weeks a year however. The veteran says his mother never remarried however she had several long-term boyfriends. The first long-term boyfriend entered the picture around the time of the veteran's birth, this gentleman died of a heroin overdose when the veteran was 6 years old. His mother then started another long-term relationship, they are still together, the veteran says he considers this man to be his stepfather/father figure. He maintains a good relationship with this man as well as then "outstanding" relationship with his mother. The veteran notes that his mother lives in Massachusetts and he has not been able to see her in the past 2-1/2 years although they talk several times a week. The veteran is hopeful that he will be able to buy a house and have his mother, her boyfriend and the veteran's nephew all moved to Ohio so that he can take care of them. The veteran says he has an "okay" relationship with his biological father although he said "we just don't talk very much, we don't have much in common." When asked to describe his childhood the veteran says it was "okay, there was a lot of issues. I had everything I needed and occasionally stuff I wanted." The veteran says at the time he thought his childhood was very good and that he was spoiled however he says looking back on the situation and comparing his childhood with the childhood of different people he has met over the years he realizes his childhood was not necessarily very good. The veteran says his mother was using drugs during his childhood although she stopped her drug use when the veteran was 14 years old. When asked about physical or sexual abuse the veteran says "just small (stuff), hitting and stuff." b. Relevant Occupational and Educational history (pre-military, military, and post-military): The veteran says that he graduated from high school in 2008, when asked how he did in school he says "not good", he says his grades were "roughly D's and C's. I had pretty severe anger issues. I just wanted to fight everybody." He did not repeat any grades although he had to take night school the last semester of classes for English and math so he could graduate. He did not participate in any special education services. The veteran did not participate in any extracurricular activities. While in high school the veteran worked for Sears as a mechanic. The veteran says that after graduating from high school he decided to join the military because "there was nothing there." The veteran felt that if he stayed at home he would "be deeper into drugs." The veteran served in the Army from 2008 until 2014, his MOS was 11B, the veteran received a general discharge with a final rank of E-5. The veteran says he was administratively discharged for misconduct, he had received a felony conviction. The veteran was deployed to Iraq in 2010/2011 into Afghanistan in 2012. The veteran says that he moved to Ohio to move in with one of his friend's family. The veteran says he was on probation for the felony conviction in Hawaii and in order to relocate from Hawaii he had to be able to prove he had a job and a place to live. He worked for his friend's father for 2 or 3 months doing interior paining until he got a better job. The veteran worked for 2 months at Columbus Castings, he stopped working after a failed suicide attempt in 2015. The veteran says he has recently appealed a Social Security Disability denial, he is hopeful he will eventually qualify for these benefits. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): The veteran says he currently sees Dr. McGill for psychotherapy although he notes she is on maternity leave currently. The veteran says that therapy was "going great", and he is hopeful he will be able to return to therapy upon her return. The veteran currently sees Dr. Schwartz for psychiatric services, he is prescribed Zoloft, prazosin and quetiapine. When asked how the medications are working for him the veteran says "I haven't seen much of a difference." The veteran says that in April 2015 he had tied a rope to a guard rail, he tied the other in to his neck he then drove away in his truck the rope apparently broke however he sustained significant internal scarring to his neck and currently has a tracheotomy and feeding tube. While in the military the veteran completed the ASAP program twice (following DUIs), he also recently completed the SATP program through Chillicothe. d. Relevant Legal and Behavioral history (pre-military, military, and post-military): The veteran says he was frequently suspended while in school for fighting or misconduct towards teachers. While in the Army the veteran received one article 15 in 2011 for DUI, he says they did not pursue the second article 15 proceedings following his second DUI because being separated from the military. The veteran reported being arrested in 2011 for DUI, in 2013 he was arrested and convicted of a felony for unauthorized entry into a vehicle. He received his second DUI in 2014 however he says his lawyer was eventually able to get the charges dropped. The veteran is currently on probation for 3-1/2 years for the felony conviction. e. Relevant Substance abuse history (pre-military, military, and post-military): When asked about his current alcohol use the veteran says that "currently I'm trying to do the sober thing" the veteran says he last drank "just after Christmas", he says he had 3 L of Mad Dog 20/20. The veteran says he would have to mix the liquor with ice so that he could drink it. In the past the veteran says he has poured alcohol straight into his feeding tube. When asked about current drug use the veteran denied any. Veteran says he last had any drugs in late 2014, at the time he was using cocaine. The veteran says he stopped his drug use because he is on probation. f. Other, if any: ===================================================================== **IMPORTANT NOTE** ---> There is a glitch in the DBQ reporting software such that if the examiner does not check off any of the boxes in Section II, Number 4 ("PTSD Diagnostic Criteria") [below], because the Veteran does not exhibit those symptoms, the software will produce "No response provided", which makes it sound as if the examiner simply forgot to answer those items, which is not the case. In this instance the software should, instead, produce something like, "No PTSD diagnostic criteria were found during this exam." ===================================================================== ===================================================================== **IMPORTANT NOTE** ---> There is a glitch in the DBQ reporting software such that if the examiner does not check off any of the boxes in Section II, Number 5 ("Symptoms") [below], because the Veteran does not exhibit those symptoms, the software will produce "No response provided", which makes it sound as if the examiner simply forgot to answer those items, which is not the case. In this instance the software should, instead, produce something like, "None of the listed symptoms were found during this exam." ===================================================================== 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: Only one stressor was elicited from the veteran, he was rather uncomfortable during this portion of the evaluation and since the stressors are being conceded the examiner chose not to inconvenience the veteran by forcing him to recall more than 1 stressor. The veteran says while he was in the convoy the vehicle in front of them was hit by an IED and flipped over. The veteran says he was afraid that all of the occupants were dead, fortunately they were able to survive. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- No response provided 5. Symptoms ----------- No response provided 6. Behavioral Observations -------------------------- No response provided 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- On a brief mental status exam he was able to freely recall 2 of 3 words presented after a brief delay, he was able to recall the final word after being provided with a simple verbal prompt. He was able to recall 6 digits forward and 4 digits backward. He was able to complete a serial 7 subtraction task with no errors to 7 places. He was able to spell the word WORLD forwards and backwards. He was able to complete simple 2 digit addition and subtraction. His responses to proverbs were good. Although the veteran denied current suicidal ideation saying "I don't want my mom to bury me", however he says that "if my mom died ..." (He would seriously consider making another suicide attempt). The veteran denied any homicidal ideation. He denied hallucinatory experiences. When asked to describe his mood on most days the veteran says he is "depressed and anxious." The veteran reports significant episodes of anxiety says he has "never had one where I'm frozen." Based on his report of symptoms he would appear to be depressed, anxious and suspicious. The veteran says he forgets "simple things", he has never been diagnosed with a head injury although he claims he suffered a concussion in the military where he was momentarily disoriented. The veteran says he knew that if he sought medical attention he would be taken off admission status and he felt he could not do that to the soldiers under his command so he convinced the medic to not report this incident. While the veteran complains of memory problems he did not display significant memory problems during the evaluation today. The veteran says he has significant problems motivating himself saying that occasionally he still will stay in bed all day. He says this occurs about 2-3 times a week. Socially the veteran described himself as being isolated saying "I have a hard time connecting with people." The veteran says "I don't talk to anyone." The veteran says the only activities he engages in is to go to the gym 2-3 times a week "if I can." He describes his energy level is "awful" saying "other than the gym I can't exert too much." The veteran says that occasionally he may go over to his female friend's house while she is at work and spend time with her dogs. The veteran says that he averages 4-5 hours of sleep "lately, he feels that the weeks leading up to the different C&P examinations have been hard on him prior to this he was getting "around 6" hours of sleep per night. The veteran says he has difficulty falling and staying asleep. The veteran says he has dreams/nightmares "at least 3 times a week." The veteran says although he may try to take a nap "it's just more me laying there." The veteran says he tends to avoid situations involving a lot of noise. He also attempts to avoid talking about his traumatic stresses. He appeared to be particularly relieved when the examiner said it was only necessary to focus on one traumatic event. Based on his self-report veteran reports exaggerated negative beliefs about himself and the world, he tends to blame himself scribed traumatic stressor saying that he was too complacent. The veteran describes his temper control is being currently "fairly good", historically prior to the military he appears to have had very poor temper control. The veteran was administered the MMPI-2-RF, although it appears he understood and responded to the items in a somewhat consistent manner remainder of the profile is not able to be interpreted due to an over-reporting of symptomatology that is not common even in individuals with known severe psychopathology. There are a number of potential reasons for this profile to include it being a "plea for help", it may be a phenomenologic style to over report and to be traumatized (this pattern is frequently seen in Dependent and Histrionic Personality Disorders and Depressive Mood Disorders) or the individual is trying to look worse than they are for some secondary reason. Unfortunately it is impossible to determine the reason behind this pattern of responding in this case without resorting to speculation. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. Clinical Psychologist Signed: 01/21/2016 16:50 01/21/2016 ADDENDUM STATUS: COMPLETED C&P Exam completed in Capri by PhD; procedure code 99456. /es/PhD Clinical Psychologist Signed: 01/21/2016 17:28 Any assistance or opinions on this matter are greatly appreciated!!! Thank you for your time and for reading this as well!
  15. Hello everyone, I am exploring a situation where regarding potential informal claims fo secondary conditions found during C&P exams. Adding in BVA instructions, this might be a situation where the VA might have dropped the ball on manifesting them into actual claims. Please note that the time period for this is 1995-2000, but it might also apply to later exams. In addition, the identified conditions were SC years later after this claim was closed. Some might read this and think that it might be a long shot or impossible, but I have read various opinions about this and wanted to ask about this approach. It might seem a bit unusual given the circumstances, but I am pulling together ideas and concepts from various resources and am asking for granular answers to my granular questions. Given these parts: Part 1 http://www.hadit.com/veterans-affairs-claims-self-help-guide/ An Informal claim is some type of communication to your local regional office in which you state you intend to apply for disability compensation. This communication can be a written letter, or fax, a telephone call or even an email. The best way, however, is something in writing. When a claimant makes an informal claim with VA, they need to clearly identify the disability for which they intend to apply for, give the VA your SSN and dates and branch of service, and make sure you send it via certified mail with return receipt! After you have sent your informal claim to VA, you have up to one year to send the VA your Formal Claim. In this one year period, I would recommend that you get together all of your medical records and so forth that will support your claim. If you send the VA your formal claim within the one year time period of the informal claim and VA grants your claim, the effective date, or the day you start to receive disability compensation, is the date of your informal claim. This could mean a lot of money in retro! Part 2 38 CFR 3.155 - Informal claims (a) Any communication or action, indicating an intent to apply for one or more benefits under the laws administered by the Department of Veterans Affairs, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within 1 year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim. Part 3 BVA instructions to the RO as follows: "The examination should include an evaluation of, but not limited to, the above forementioned disabilities. The examiner should be requested to assess any and all disabilities present and render an opinion as to whether they are etiology related to service. A complete rationale should be provided." Questions 1. The VA said "any communication". If a "telephone call" (part 1) assumed to be to 1-800-827-1000 constitutes "any communication", would statements from a veteran documented by a VA C&P examiner be included? 2. If an "informal claim must identify the benefit sought" and "any communication, indicating an intent to apply for one of more benefits" are required, already being in a C&P exam demonstrates an intent and actual filing of disability benefits. Is this sufficient to prove intent to seek additional direct or secondary disability benefits? 3. If additional disabilities are identified through subjective statements from the veteran and objective diagnosis by the C&P examiner - but an opinion regarding SC was never rendered either for or against SC (part 3, BVA instructions), would those conditions be still considered open or would the mere lack of opinion be assumed as a denial? 4. (similar to previous question) If a C&P examiner fails to follow specific BVA instructions regarding opining for/against additional diagnosed conditions, is there a CFR/CAVC rule that states those conditions are automatic denials? 5. If the reported/diagnosed additional disabilities were reported during a C&P exam meet the requirements of an informal claim, a formal claim was not on filed already, and if the veteran was never sent an application form, would an informal claim for secondary disabilities still be considered open? Sorry to bug everyone about this, but the gears in my head have been spinning about these questions. Thanks!
  16. My claim back in 2014 it was found that my tongue scar was 7822-7800 rated at 10% due to the Characteristic of Disfigurement width measurement. My 2015 reconsideration claim to add a separate code of 7804 for the account that it is also painful was successful, but, they removed the 7800 code for head, face, or neck. The changed it to 7822-7802 so it's still 10% lol....those bastards. So my question is, does it still count as head, face, or neck 7800? It's my understanding that every conflict should be resolved in favor of the higher rating. I mean...it would be a CUE to not see that my tongue is inside my head lol! Thank you!
  17. I recently finished a series of C&Ps for various conditions and I was hoping to get some input on just what exactly it all means - I was wondering what if any kind of rating might I be looking at? Is there a possibility for getting back pay? What can I do (possibly in an appeal) to do more to strengthen my case? At this point my case should be done with the gathering evidence phase (I can't check because ebenefits is being weird). All C&P's are done and everything that needed to be turned in is (I hope). The first C&P/DBQ I'd like assistance with is my claim for "Lower Back Condition". Originally I had claimed "chronic lower back pain" only to later find out that really isn't a thing and thus I was denied. When I went in for this most recent exam the reviewing doctor first went to my C-File and saw that I had claimed "chronic lower back pain" back in 2004. He then went into my military treatment record and found considerable amounts of treatment records for several issues in my lumbar spine and beyond. "They should have connected you back in 2004" he said to me. Sufficed to say that his positive first impressions put me a little more at ease with the C&P (which normally turns me into an anxious, nervous wreck). I've now gained access to the DBQ and would like any information that you well informed folks could provide. I've cut it down as much as I thought I could. If a question is missing and/or option is missing assume it wasn't checked. All non-pertinent information I cut out and did some heavy editing as far as formatting goes. Here it is: Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: VA medical records. 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? [X] Yes [ ] No Thoracolumbar Common Diagnoses: [ ] Ankylosing spondylitis [X] Lumbosacral strain [ ] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: LS strain, chronic, with LLE radiculopathy Date of diagnosis: 2000s 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): During military service, the Veteran did develop chronic left lower back pain with radiation down the left buttock to the calf. On 6/10/2003, an MRI of the LS spine was performed with the following findings: Broad based posterior/central disc bulging at L4-5 without associated neural impingement. After service discharge in 2004, the Veteran continued with intermittent lower back and LLE problems. Repeat lumbar MRi in 2009 was read as normal. Currently he continues with chronic daily left lower back pain with LLE weakness and paresthesias. He is taking Ibuprofen and has a TENS unit as needed. He deniesbowel/bladder/sexual dysfunction related to his lower back. b. Does the Veteran report flare-ups of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: Increased pain and stiffness c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words. Stiffness/LLE radiculopathy 3. Range of motion (ROM) and functional limitation -------------------------------------------------- a. Initial range of motion [X] Abnormal or outside of normal range Forward Flexion (0 to 90): 0 to 75 degrees Extension (0 to 30): 0 to 20 degrees Right Lateral Flexion (0 to 30): 0 to 30 degrees Left Lateral Flexion (0 to 30): 0 to 30 degrees Right Lateral Rotation (0 to 30): 0 to 30 degrees Left Lateral Rotation (0 to 30): 0 to 30 degrees If abnormal, does the range of motion itself contribute to a functional loss? [ ] Yes (please explain) [X] No Description of pain (select best response): Pain noted on exam on rest/non-movement If noted on exam, which ROM exhibited pain (select all that apply)? Forward Flexion, Extension Is there objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue of the thoracolumbar spine (back)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): There is localized tenderness over the bilateral paralumbar muscles and the left SI joint and left sciatic notch. b. Observed repetitive use: Is the Veteran able to perform repetitive use testing with at least three repetitions? [X] Yes [ ] No Is there additional loss of function or range of motion after three repetitions? [ ] Yes [X] No c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Not currently flared up. d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: Not currently flared up. e. Guarding and muscle spasm Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Muscle spasm: [X] Not resulting in abnormal gait or abnormal spinal contour Provide description and/or etiology: Left lower back muscle spasm is noted today. Localized tenderness: [X] Not resulting in abnormal gait or abnormal spinal contour Guarding: [X] None f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: [X] None 4. Muscle strength testing -------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Hip flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Great toe extension: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [ ] Yes [X] No 5. Reflex exam -------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus Knee: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Ankle: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam --------------- Provide results for sensation to light touch (dermatome) testing: Upper anterior thigh (L2): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Thigh/knee (L3/4): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Lower leg/ankle (L4/L5/S1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Foot/toes (L5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [X] Negative [ ] Positive [ ] Unable to perform Left: [ ] Negative [X] Positive [ ] Unable to perform 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe b. Does the Veteran have any other signs or symptoms of radiculopathy? [ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply) [X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) If checked, indicate: [ ] Right [X] Left [ ] Both d. Indicate severity of radiculopathy and side affected: Right: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe Left: [ ] Not affected [X] Mild [ ] Moderate [ ] Severe 10. Other neurologic abnormalities ---------------------------------- [ ] Yes [X] No 12. Assistive devices --------------------- [ ] Yes [X] No 13. Remaining effective function of the extremities --------------------------------------------------- [X] No 14. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [X] Yes [ ] No If yes, describe (brief summary): Vital signs are stable; Lungs are clear; Heart is without m/g/r; Abdomen is soft, and without masses or organomegaly or tenderness; Genitalia are normal, no hernias or testicular lesions, the testicles and epididymii are tender to touch bilaterally; b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No 15. Diagnostic testing ---------------------- a. Have imaging studies of the thoracolumbar spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis documented? [ ] Yes [X] No b. Does the Veteran have a thoracic vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): Repeat lumbar MRI has been ordered and is currently pending; when completed and reported, I will review it and add any additional comments as indicated. 16. Functional impact --------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [X] Yes [ ] No If yes describe the impact of each of the Veteran's thoracolumbar spine (back) conditions providing one or more examples: The Veteran's current lower back condition would limit his ability to perform repetitive heavy lifting, pushing or pulling. 17. Remarks, if any: -------------------- The Veteran is claiming service connection for a lower back condition. Opinion: It is as least as likely as not that the Veteran's current lower back condition is proximately due to or caused by military service. Rationale: The C file was reviewed. The STRs do document a two year history in 2002 of chronic lower back pain with LLE radiculopathy. This is also noted on separation exam in 2004. I was able to elicit the same symptoms ongoing today, as well as to confirm this on phyiscal examination. Repeat lumbar MRI has been ordered since the last study was in 2009; when completed and reported, I will review it and add any additional comments as indicated. Thus, the service connection is substantiated. 12/23/2015 ADDENDUM STATUS: COMPLETED The Veteran underwent a lumbar MRI on 12/21/2015 with the following findings: L3-4: Mild facet arthrosis with minimal posterior disc bulge L4-5: Mild facet arthrosis with minimal posterior disc bulge L5-S1: Mild facet arthrosis with minonal posterior disc bulge ------END------- Any help interpreting this would be greatly appreciated. The "service connection is substantiated" is pretty straight forward. I'm curious whether or not I have a chance at getting the SC backdated to my original claim. It seems to me (a total non expert) that the evidence is there to support it. I am also curious about whether or not I can refute some of the conclusions that this doctor came to. While an awesome C&P doctor a back expert he is not. Since the writing of the C&P I had a chiropractor evaluation who found several more things than this doctor did. I'm curious if any of it will be enough to make a 10% difference when the rating comes down. In addition I am curious if within my C&P as well as the most recent chiro consult if there isn't evidence for a possible future claim for nerve pain in my lower body. "Many times spinal conditions have other conditions that contribute to the severity of the spinal condition. For example, many spine conditions also cause radiculopathy. These secondary conditions can sometimes be independently ratable." In my C&P I believe I meet all these conditions. I am diagnosed with lumbosacral strain - chronic, as well as Lower Left Extremity radiculopathy. In addition the C&P also diagnosed me with LLE weakness and paresthesias. The following is a list of conditions that the Chiropractor diagnosed me with just 8 days after the C&P doctor finalized his report. ----------Chiropractic Evaluation-------------- LOCAL TITLE: PM&R CHIROPRACTOR CONSULT RESULT STANDARD TITLE: PHYSICAL MEDICINE REHAB CONSULT DATE OF NOTE: DEC 31, 2015@11:04 Midback pain: medial scapula, left worse than right Quality: Burning (small area "about the size of a dime") Radiating: Patient Denies 0-10: 9/10 Timing: Intermittent Worse: working in a "hunched" or bent over position. Better: Standing up /stretching Low Back Pain: Thoraco-lumbar and lower L4-5-S1. Quality: Dull/Ache/sometimes sharp/Throbbing Radiating: buttock/thigh and foot ("tasered"), left worse than right 0-10: 6-7/10 Timing: Intermittent Worse: Standing/coughing while bent over Better: changing positions/activities Trunk ROM: Flexion:Mod dec Pain:Severe Extension:Mild dec Pain:No pain Rotation:Mild dec Pain:No pain Lateral Flexion:Mild dec Pain:No pain Muscle Atrophy: No Seated SLR: Positive L Supine SLR: Positive R (low back pain) Hip hyperextension test: Positive R Kemps test: Negative R L Spinous Process Tenderness: T3-7, L2,3, Right SI Myofascial Tenderness: Bilateral Rhomboids, Thoraco-lumbar paraspinals bilaterally. Lumbar MRI 12/21/2015 Impression: 1. Mild facet arthrosis and minimal disc bulges of the lower lumbar spine without thecal sac or neuroforaminal stenosis. Oswestry Disability Index Questionnaire Section 1 -- Pain Intensity: 2. The pain is moderate at the moment. Section 2 -- Personal Care (Washing, Dressing, etc.): 2. It is painful to look after myself and I am slow and careful. Section 3 -- Lifting: 2. Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed e.g. on a table. Section 4 -- Walking: 1. Pain prevents me walking more than 1 mile. Section 5 -- Sitting: 3. Pain prevents me from sitting more than one-half hour. Section 6 -- Standing: 2. Pain prevents me from standing for more than 1 hour. Section 7 -- Sleeping: 2. Because of pain, I have less than 6 hours sleep. Section 8 -- Sex Life (if applicable): N/A Section 9 -- Social Life: 3. Pain has restricted my social life, and I do not go out very often. Section 10 -- Traveling: 2. Pain is bad but I manage journeys over two hours. DISABILITY INDEX SCORE: 38% Segmental Dysfunction: L3LP, RPIN, RAI_Sacrum, T3LP, T5LP Assessment: 1. Lumbar: Segmental dysfunction 2. Lumbar: strain 3. Pelvic: Segmental dysfunction 4. Sacrum: Segmental Dysfunction 5. Thoracic: Segmental dysfunction Alright. If you've made it this far thanks for taking the time to read this massive wall of text. If you have some information or experience to offer let me thank you in advance!
  18. I have a C&P scheduled today for TDIU...and I am so stressed out I am sick. This is my second evaluation for PTSD and Kidney problems as it was on appeal. I am currently 70% combined and SSDI has me rated 100% for PTSD..<service connected .....and a back injury that is not service connected. My question is what do I need to do this time to not sabotage myself? The last C& P I had a young lady spend not more than 6 min with me and I explained what day to day life was like for me.....I requested the copy of the C&P report and she recommended no increase because she put on the report that since I was able to watch some TV...I was still employable. My appeal goes all the way back to 2010 when I first applied for TDIU. Would I be better to put down on paper what day to day life is like for me and give it to examiner when I go in today? I am rated for agoraphobia lumped into my PTSD, I have panic attacks, literally get sick in bathroom or get cramps so bad I have to use restrooms when I go out in public, I no longer drive as my wife does. I yell at my daughters and wife all the time, I do not sleep due to nightmares, and when I am not I frequently checking doors and windows. Started to drink in the last three years....so I dont have to feel. I have great fear of being targeted by people/terrorist because I am a veteran and fly a flag out in my front yard....I know it not rational. Ashamed and do not like to be identified as a veteran, I feel betrayed by my country to have went to Iraq and watched my buddy's get killed, have my life torn to nothing and all for what......the president hands it back over to the terrorist.
  19. Hello all. I would like to thank all of you for your work on this site. I am a long time lurker, first time poster. I received my C&P Results back and would appreciate any feedback. I understand that there is no way to be fully accurate when trying to guess a rating based off of this information. I am just under immense stress lately as I have watched my life fall apart piece by piece over the last few years. I had good rapport with the interviewer but don't know what to make of some of the things he wrote. Thanks in advance for your insights you all do great work here. SECTION I: ---------- 1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [X] Yes [ ] No ICD code: 309.81 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: PTSD ICD code: 309.81 Mental Disorder Diagnosis #2: Alcohol Abuse, in Remission ICD code: 305.03 Mental Disorder Diagnosis #3: No response provided. b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): No response provided. 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes [ ] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [X] Yes [ ] No [ ] Not applicable (N/A) If yes, list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: Currently, no symptoms are attributed to alcohol abuse, because alcohol abuse is in remission. All symptoms are attributable to PTSD. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with reduced reliability and productivity b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [X] Yes [ ] No [ ] No other mental disorder has been diagnosed If yes, list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis: Currently, no occupational or social impairment is attributed to alcohol abuse, because alcohol abuse is in remission. All occupational and social impairment is attributable to PTSD. c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence review ------------------ In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed. a. Medical record review: ------------------------- Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [X] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: MTR - govt and nongovt, VA documents and forms, b. Was pertinent information from collateral sources reviewed? [X] Yes [ ] No If yes, describe: Buddy or lay statement from who was Veteran's ex-girlfriend, 2. History ---------- a. Relevant Social/Marital/Family history (pre-military, military, and post-military): Relevant social history, birthplace, (mostly) happy childhood memories, (-) homeless currently, (-) rent currently, (+) own currently, (#0) of household occupants in addition to Veteran, (-) close friends, Veteran states that he feels estangement from others, he reached out to one of his military friends two weeks ago, this was the first tome to do that for one year, Veteran used to be active on Facebook, but he is no longer active on facebook, he began experiencing the idea that his thoughts were being communicated in a certain way by others, (-) attend social activities, (+) hobbies or interests, Video games, all kinds, grand theft auto, mad and football, wrestling, Veteran used to be an avid sports fan, he used to know the lines of college and professional football teams, he does not do that anymore, Relevant marital history, (S) civil status, he used to have a girlfriend, they were together for 3 years, he used to yell and scream at her, he states that it took everything within him to keep from hitting her, but he never hit her, she left and she did not come back; Veteran states he never assaulted his ex-girlfriend prior to their breakup; alternatively, he states that he choked his girlfriend in the heat of the moment 2 times, but she did not pass out, (#0) number of marriages, (#0) number of divorces, (#1) number of childrren y/o son, Veteran's son's mother does not allow Veteran's son to have unsupervised visits with Veteran, Relevant family history, (-) emotional or mental problems, (+) heart disease, PGF has CAD and h/o CABG, (+) both parents living, (-) close to them, he rarely talks with them, (#1) siblings living, 1 sister, (-) close to her, they have not spoken for 2 years Pre-military, Veteran states he killed his first animal at 10 y/o, which was a deer, and he gutted and cleaned it at that age. Post-military, Veteran states that he carries a gun wherever he goes. He was closer to his family and other people pre-military and military. Post-military, he has become distant with family and friends. His parents live inand have a home there . Post-military, after finishing his contract work in which he mostly worked on military instillations for the federal government, he lived with his parents for 2 months in He moved f to to go to College in 2012. He did not start having problems from symptoms of PTSD until after he finished his contract work, which was more like being in, rather than out of, the military, and began living more as a civilian. b. Relevant Occupational and Educational history (pre-military, military, and post-military): Relevant occupational history, (-) currently working outside the home, (2012) year last worked outside the home, (F) P = part time, F = fulltime, (security) type of work, (nothing) current source of income, Veteran indicates that he has used up his savings and now he is behind on many of his bills, (+) emotional or mental symptoms associated with occupational problems, Veteran was fired from his last two jobs, Relevant educational history, (+) learning difficulties, (-) learning disabilities, (he has two years of college) level of education, (+) emotional or mental symptoms associated with educational problems, difficulty concentrating, Veteran graduated from HS at 18 y/o. He went to college for one year. He worked seasonal work, restaurant work, cabinet factory, met a woman, had a son, was in and out of legal troubles, and entered the USA at 23 y/o. He was discharged from the USA at 27 y/o. He worked for as a regional supervisor for 5 years. . ; Veteran states he was a distinguished soldier during basic training. He became the best mechanic while in stationed in Germanny. He was a leader and NCO in the Ranger battalion. He did not get DUIs and he did not get into fights. Veteran states that he laughed at the PTSD symptoms checklist when he first came back from his deployment to Iraq. but now he cannot get a job due to such symptoms. He has not been able to hold down a job for the past 3 years. c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Relevant mental health history, (-) mental health care before military service, (-) mental health care during military service, (+) mental health care after military service, (#0) previous suicide attempt(s), (#0) previous hospitalization on psychiatric ward(s), (#0) previous court orders for involuntary treatment, (+) currently seeing a provider for the purpose of medication management, (-) currently attending individual psychotherapy and/or group therapy, he used to go to groups, he lost his driver's license, therefore he has not been going, because it is difficult getting there, (+) h/o severe emotional trauma, (-) h/o head trauma, (-) h/o evaluation for TBI, (+) current emotional or mental problems, (+) mood often blue or sad, (+) anger, (+) h/o ever experiencing seven or more days of manic excitement (i.e., abnormally, discretely, and persistently elevated, expansive, or irritable mood), decreased need for sleep, racing thoughts, or pressured speech, Veteran states that he has gone for many days without sleeping, he would keep busy because he was unable to sleep, he used to self-medicate insomnia by drinking alcohol to the point of blacking out, he has h/o anxiety and paranoia, racing thoughts, increased goal directed behavior (in terms of playing a video game), agitation (in terms of pacing around the apartment), he was not talking faster or more than usual, no significant change in self-esteem or grandiosity, no significant distractability, (+) behavior for the purpose of pleasure with potentially painful consequences (alcohol problem), (+) h/o of hallucinations, he used to have these when he was drinking alcohol, he used to have alcohol hallucinosis, he has been sober since June 2015, (+) h/o delusions, he has h/o delusions of reference, Prescribed medications, List, propranolol, sertraline, and trazodone; he was remotely taking aripiprazole and valproate, he was taking quetiapine when going through inpatient treatment for alcohol abuse, he has h/o risperidone and risperidone-associated akathisia, (+) adverse events with one or more of these, his sleep is too deep with trazodone, then he has disturbing dreams, then he cannot wake up out of these disturbing dreams, because his sleep is too deep, (-) beneficial effects with each of these, propranolol was previously helpful while he was on risperidone to decrease the akathisia associated with risperidone, sertraline is not yet producing a beneficial effect, Family mental health, Please see above under "relevant family history." d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Relevant legal history, (+) symptoms associated with legal problems, (+) h/o arrests for assault, battery, or violence, (+) h/o arrests, convictions, or sentencing (to jail or prison), (-) currently on parole or probation, (-) current conservator or guardian, (+) h/o DUI, #1, Relevant behavioral history, (+) symptoms associated with behavioral problems, Veteran states that he does not talk with anyone, he does not do anything, he enrolled in school, he cannot deal with that anymore, he dropped out of College, he cannot deal with the people there, he believes he is viewed by others as a time bomb, after he was arrested for eluding an officer. (yesterday) last time to be in a heated argument with another person, (June, 2015) last time that to be in a physical altercation with another person, (poor) quality of sleep generally, Pre-military: Veteran had reckless driving charges and assault with a deadly weapon charges prior to USA service. He was charged with reckless driving. He ended up doi of house arrest for reckless driving. He took assault with a deadly weapon to a jury who did not find him guilty as charged. It was determined that he was defending himself, and he was absolved of any wrong doing. Military: Veteran has one negative counseling statement for missing formation one morning due to oversleeping when they had a power outage, when his roommate was on leave, but other than that he did not have any other LOCs, no LORs, no Article 15s, and no other non-judicial or judicial punishments. Postmilitary: Veteran was arrested in 2013, and he was placed in a mental health safe cell while in jail, because he drove off from a traffic stop away from an officer. He was initially written up for felony eluding, but the charges were plea bargained down to a misdemeanor. Veteran has pending charges. He has a warrant out for his arrest. This is for criminal speeding (99 mph in a 45 mph zone). e. Relevant Substance abuse history (pre-military, military, and post-military): (+) tobacco during past 30 days, (today) when last used, (-) alcohol during past 30 days, (July 2015) when last used, he got out of treatment June 8th, he relapsed in July, for 2 days, (+) h/o alcohol problem or alcohol abuse, (-) illicit drugs during past 30 days, (prior to March, 2014) when last used, he has not used spice (synthetic MJ since prior to his first inpatient treatment program, (+) h/o inpatient or outpatient treatment for alcohol or illicit substances, 2 times, (+) currently attending AA, NA, or other support groups, Veteran does not believe that he suffers from alcoholism, Veteran smoked a joint of MJ when he graduated from HS, he did not smoke MJ during the military, and he smoked MJ less than 6 times after the military. He drank alcohol 2 times during HS, he was a social drinker during college and the military, while in Germany, and he became an alcoholic after the military. He was drinking a lot with his friends, at the time of his deployment to Gerrmany, from dusk until dawn. Other times, he could drink until 2 AM, go to sleep, wake up at 5 AM, go to PT, and be fine, while in the regular Army battalion, but he was not able to keep that lifestyle while in the Ranger battalion, because they put him through too much. Veteran does not like talking with anyone about anything, even the weather. Veteran feels uncomfortable when in large groups of people. This triggers intense urges for drinking alcohol. Living with his emotions and feelings is more difficult without alcohol than with alcohol. f. Other, if any: No response provided. 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: 1. Military Combat Trauma (Veteran observed traumatic events as experienced by others, including seeing a person get his face shot off, seeing people with their heads cut off, and seeing a dead body, he claims he saw a US missile hit a minivan carrying an entire family,) Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No b. Stressor #2: No response provided. 4. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. Do NOT 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 and Statistical 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: [X] Witnessing, in person, the traumatic event(s) as they occurred to others Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: [X] Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). [X] Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). [X] 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). [X] Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s). [X] 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 the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, 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: [X] Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad,: "No one can be trusted,: "The world is completely dangerous,: "My whole nervous system is permanently ruined"). [X] Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead to the individual to blame himself/herself or others. [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). [X] Markedly diminished interest or participation in significant activities. [X] Feelings of detachment or estrangement from others. [X] 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: [X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. [X] Reckless or self-destructive behavior. [X] Hypervigilance. [X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: [X] Stressor #1 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Anxiety [X] Suspiciousness [X] Panic attacks that occur weekly or less often [X] Chronic sleep impairment [X] Difficulty in establishing and maintaining effective work and social relationships [X] Inability to establish and maintain effective relationships 6. Behavioral Observations -------------------------- Appearance - attire is summertime casual, grooming is average, and presently, the veteran does not appear to intermittently be in distress as he intermittently discusses his taaumas. Behavior - eye contact is intermittent, and speech is of unremarkable rate, rhythm, volume, prosody, and articulation. Speech contains profanity in many sentences. Comportment suggests that the veteran gets along adequately with this writer. Affect is neutral. Thought processes are logical, linear, and goal-oriented. Presently, the veteran does not have a formal thought disorder. Thought content is without homicidal ideation or suicidal ideation. Perceptions - the veteran presently does not appear to be responding to internal stimuli. Insight is fair. Judgment is fair. Psychomotor activity - Veteran becomes agitated when talking about his experiences in Iraq. Muscular observation shows absence of focal motor deficits. Cognitions are grossly intact. Abstractions demonstrate at least average capacity for logical reasoning and systematic thought. 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- REQUESTS AND FINDINGS A. CLAIM TYPE - ORIGINAL, DBQ PSYCH PTSD Initial, the following contentions need to be examined - PTSD, The VARO has verified the veteran's combat service and the veteran has the following combat medals Combat Action Badge, Veteran is a y/o divorced, unemployed EA who served in a Ranger battalion while serving in the USA and experienced military combat while serving in Iraq. Veteran served in the USA from 2003 to 2007. He was in the motor pool division of the Ranger battalion. He observed traumatic events as experienced by others, including seeing a person get his face shot off, seeing people with their heads cut off, and seeing a dead body. He claims he saw a US missile hit a minivan carrying an entire family, because the US forces wanted to kill one enemy combatant inside the minivan. Veteran saw a VAMC on 10/01/2014, who diagnosed him with and treated him for PTSD. Veteran experienced military combat stressors. Currently, at night he has dreams, in which he cannot get his gun to shoot, because it will not fire. During the day, he has uncontrollable thoughts. He visions someone getting shot. Either he is shooting at the person getting shot or groups of people are shooting at the person getting shot. He hears someone getting shot. He states that it makes a very distinct sound. Thunderstorms, trigger he to "lose it," whereby he becomes diaphoretic, comes to, and finds himself on the floor in the prone position, after he has pulled his ex-girlfriend to the floor with him. He has trouble sleeping for one week following such events. Firecrackers on the 4th of July trigger he to "lose it," whereby he finds he has pulled his son to the ground with him, causing abrasions to his son's B/L knees. Veteran states that he avoids people, because when they find out that he is an Iraq War veteran, then they have a tendency to talk with him and ask him questions about his experiences. He states that he hates it when they state that they understand, and he states that they do not understand, because they were not there. Veteran voices his suspiciousness and states that as soon as groups of people at AZU, where he was in school, and groups of people where he has been employed find out that he has issues, then people talk about him and he is talked about. Veteran states that people make jokes as to when would he be going postal and start shooting up the office. He states that he knows that others are talking about him, because when he goes into a room, then everyone stops talking. Veteran states that once people become uncomfortable with someone, then they plot and scheme. Veteran used to be a baseball player, where he learned that being calm and controlled worked to his advantage, but he states that he has lost the ability of being calm and controlled in order to work to his advantage. He recognizes that he has a "short fuse" and can suddenly go from neutral to angry, agitated, and combative with the right cue, as in someone older bossing him around and telling him what to do. He states "[he] wants to punch out a window over nothing." Veteran states that if he applies for a supervisor position, then he is offered an entry level position instead. He states in the past he was able to deal with supervisors, but now he cannot deal with supervisors. One of his supervisors was talking to him as though he was a child, then Veteran took his left hand, placed it across his supervisors neck, and pushed him against the wall. His supervisor "flipped out," talked about suing him, and talked about pressing charges. Then Veteran was immediately let go. He was told that they were going to consider it as though he was never hired. Veteran admits to being high strung and states that he used to be able to filter out supervisors telling him what to do kinds of stressors, but he is no longer able to do that. He states that yesterday when he took a urine drug test for a job that he would like to get, after waiting for 20 minutes and watching the receptionist doing one thing or another on the computer, he became irate and confrontational. Veteran denies suicidal ideation. He states his father's sister's husband killed himself. Veteran states that he would never do that. He would not do it on account of his mother and his son. Work impairments include being up for 3 nights at a time without sleeping, then he falls asleep while he is doing something routine, such as tying his shoes. He states that he has missed a few jobs on account of this problem. Veteran meets the following DSM 5 criteria for PTSD. 1.) Trauma, (+) Directly experiencing the events, (+) Witnessing the events as they occurred to others, (-) Learning that the traumatic events occurred to someone close, 2.) re-experiencing, (+) dreams or nightmares, (+) flashbacks, (-) illusions or hallucinations, (+) images, perceptions, or thoughts, (+) triggers cause emotional and mental distress, 3.) avoidance, (-) activities, he enjoyed American Sniper immensely, but he states that this stirred up emotions and feelings, (+) conversations, he avoids conversations with his Ranger friends, (-) feelings, (+) people, he avoids seeing his Ranger friends, (+) places, he states he does not like the VA, people came back without eyes and limbs, he came back with emotional and mental symptoms, (-) thoughts, 4. negative feelings or thoughts, (+) anhedonia, (+) decreased interest or participation in activities, (+) distorted cognitions about the cause or consequences of the events, he states that the entire Gulf War was "&$," (+) feeling detached and estranged, (-) forgetting details about the events, (+) negative beliefs about himself, others, or the world, he states that the US federal government is "&$," (+) negative emotions, 5.) Altered arousal and reactivity (+) angry outbursts, (+) irritable behavior, (+) hypervigilance, (+) exaggerated startle, (+) recklessness, (+) self-destructiveness, (-) concentration problem, if interested, then he can concentrate really well, if not interested, then he cannot concentrate very well, (+) sleep disturbance, 6.) (+) long-term duration, 7.) (+) dysfunction, 8.) (+) not due to a medical illness or substance, Veteran has decreased productivity at work, because he has emotional and mental symptoms affecting his ability to work, interpersonal problems affecting his ability to get along well with others, and authority and submission problems affecting his ability to get along well with supervisors. These problems are secondary to symptoms of PTDS. They occasionally, but not continuously, affect reliability. Otherwise, his ability to adapt to change, maintain a regular work schedule, pay attention, concentrate, and reason, show up for the job, maintain himself on the job, and complete the job are not impaired. Alcohol abuse is in remission. Functional limitations include working under a less than supportive supervisor, working around any more than 2 or 3 other people, and working indoors. B. ELECTRONIC CLAIMS FOLDER AVAILABLE, review Veteran's electronic folder in VBMS and state that it was reviewed. Veteran's electronic folder in VBMS and was reviewed. C. If more than one mental disorder is diagnosed, comment on their relationship to one another. Alcohol abuse is secondary to insomnia, which is secondary to PTSD. Alcohol abuse is in remission. D. If more than one mental disorder is diagnosed, state which symptoms are attributed to each disorder. Currently, no symptoms are attributed to alcohol abuse, because alcohol abuse is in remission. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application.
  20. I didnt have a question, i wanted to add this to the thread about it, but it was locked. After some research I have determined that NO YOU DO NOT HAVE A RIGHT TO RECORD YOUR EXAMINATIONS. That being said not having a right to record a conversation does not mean you cannot ask. It does mean you cannot refuse the C&P examination on those grounds then appeal the decision based on the examination not being conducted. In M-21-1, Part III, Subpart iv, Chapter 3, Section A, I, regarding “Veteran’s Legal Rights at an Examination” “A Veteran has no legal right to · Be accompanied by counsel during an examination, or · Record an examination” Also in a comment by the VA General Counsel “Citation VAOOPGCPREC 04-91” regarding the question of whether or not a veteran is considered “failed to report” to a C&P exam if they refuse the examination with having an attorney present and being allowed to record the evaluation. “10. Similarly, there is no constitutional, statutory, or regulatory requirement that would allow beneficiaries to use recording devices during VA medical examinations. Again, it must be noted that the examinations at issue are investigative and preliminary in nature. Further, while case law on the subject is not extensive, it supports the conclusion that one has no "right" to record such activities. See, e.g., Baer, 142 F.2d at 788-89 (no constitutional infirmity where court reporter ordered to leave investigative-hearing room); In Re Neil, 209 F.Supp. 76, 77 (S.D.W.Va.1962) (APA does not extend to any party the right to bring a stenographer to report the proceedings at an agency hearing); Torras, 103 F.Supp. at 740 (witness in investigative proceeding did not have right under the APA to the presence of a personal stenographer). As discussed above with respect to the presence of an attorney, use of a recording device would threaten to impede free communication between the examinee and the examining physician. VA regulations do not authorize the use of recording devices at medical examinations, and we find that their use is not otherwise required by law. Thus, denial of the use of such a device would not be an adequate reason to refuse to submit to examination.” So in short you have no right to it. You can ask and if they say NO then you CANNOT use that denial as a reason to refused the exam. If you say “I wont do it without recording it” then they can write you down as basically refusing the C&P and you will near 100% certainty be denied your claim, increase, etc. That being said you may want to do the following… Ask the VA prior to the examination. I would say you should do this prior. What I would personally do (and I can’t reiterate this enough, purely for educational purposes, not legal advice, consult a lawyer) is this. a) Write the head of the department your exam is under. If say you will be going in for a PTSD examination write and/or call the head of the mental health department at that hospital. Obtain written approval to record the examination. This should be no issue as anything that is personal information/HIPPA relates to others releasing your personal information. If you are seeking to obtain the information then it SHOULD not have any HIPPA implications. Get their written permission to do so. Why written? Because if they decided to try and say no, or not allow it day of, or say it was illegally obtained you have the permission of the department head. I would also request that the Department head notify the examiner of this prior to the examiner so there are no “surprises” for the examiner day of. They should have NO PROBLEM being recorded if they are going to be honest, however some people get antsy about it. b) Obtain the Consent of the examiner. Bring in your letter as well as your recorder. Prior to the examination beginning show them the letter and let them know that the department head has approved you using a recorder. Start the recorder and State the following “I am ___YOUR NAME___ it is __TIME__ on __DATE__ and I give my consent to being recorded for a Compensation examination, In the room and conducting the examination is the following, please state your name, title and consent to be recorded” Have them state something to the effect of “I am Dr. Joe Schmoe, psychologist and I consent to this examination being recorded.” If they refuse you can either choose to go ahead with it, without the recorded or refuse to without it stating this was cleared beforehand and that the department head was to notify the examiner. You will probably be marked down as a no show or refusal and lose your claim. I think this is something that needs to be addressed congressionally and changed in the VA statutes to allow for recording. The VA general counsel tries to hide behind the veterans saying “use of a recording device would threaten to impede free communication between the examinee and the examining physician.” They want to try and make this a it will hurt the veterans so that’s why we don’t want it. In truth that is a cop out, yes of course it will change the way the examination is conducted, it will make it open and honest, no shenanigans. If the veteran wants that and this whole process is SUPPOSED TO ABOUT HELPING THE VETERAN, then the veteran has weighed the benefits and still wants it. It is a total logical fallacy for the lack of "right" to be attributed to recording devices. The two arguments i see that the VA OGC has against it are these. 1) Patient Privacy Concerns 2) impeding an open and honest exam due to a recording device. 1) the patient is the one who is initiating the recording. The only reason they could say its a privacy issue is if the recording was stolen or lost, etc. however they give us access to our patient records, which can also be stolen. This logic fails. 2) as i stated above the veteran is initiating it and the only logical reason this would not be "free" and "open" is if the examiner is conducting shenanigans. I do believe the VA has a minor concern that a vet could record then try and file a NOD based on a bad C&P stating "i didnt feel free to speak because i was recording" although this would easily be denied since the veteran initiated it and had total control over when the recording could be stopped. Have us sign a waiver to that effect that we waive the right to appeal based on "uncomfortability due to being recorded". I also find it interesting mostly because the VA DID THE SAME THING WITHOUT NOTIFICATION OR CONSENT~! The VA supposedly was concerned about the same thing as we are in our reasons for recording. examiners correctly transcribing exam responses into diagnoses or basically writing down what we responded with as well as other concerns and "red flags". So i do find it funny that we are concerned with exams but we have no right to record, but the VA can record without our knowing or consent to 'better serve veterans'. Until that day, the answer to recording your exams is you have NO RIGHT TO REQUIRE, BUT YOU CAN ALWAYS ASK.
  21. Hello fellow hard chargers. I'm an 0351/OIF combat veteran who was involved in the initial invasion of Iraq back in March, 2003. I witnessed and did things that were pretty horrific. The last few years have been extremely difficult for me -- and within the last year, in particular, PTSD symptoms have gotten the best of me and for the last 5 months, after being let go from my previous job (due to lashing out at several clients), I have been unable to procure steady employment. My father, who is a Vietnam veteran, told me about the about the possibility of getting compensation for PTSD. Until a couple of months ago, I didn't know this was even a possibility. So I did my research, filed a claim, and then entered treatment at the VA here in Southern California. Within a week, I was diagnosed with PTSD, and they prescribed me two sets of medications - Prazosin for anxiety/panic attacks, & Gabapentin for nightmares. I just started the medications this week and I've already noticed a decrease in nightmares and panic attacks -- which up until last week were occurring 3 to 4 times a week - sometimes every night. They've also started me on PE (Prolonged Exposure) Therapy which I'm doing but honestly -- therapy inside the stagnant walls of the VA are enough to give anybody nightmares!! But I'm grateful that the therapy is available. Just today,I got a notification for a QTC (C&P) exam at a private facility here in Los Angeles. From what I've read online, it seems this process is happening very quickly -- I only filed my initial claim on July 1st. What can I expect from this interview? Like everyone else here, I would gladly except the highest rating possible, since I really do need (and I believe deserve) the monetary assistance to get me through this time of my life. Can I expect them to have already received the medical records from the psychiatrist I've been seeing at the VA - as well as the notes from my initial consultation with the PTSD specialist? Also, with this examiner, do they go into the details of events that occurred while I was in Iraq? I really hate the idea of having to discuss those details again with a complete stranger -- it was hard enough with the VA psychiatrist. And do you have any other suggestions in general as how I should prepare? The medications are helping with certain sleep issues-- should I bring that up or will that lower my chances of getting a higher rating? Thank you all for your input. It is greatly appreciated...
  22. Ok, here we go again. Got a call a few days back from a DRO at the Houston VARO. They are doing a de novo review of my case, and scheduled me for a series of C&P examinations, which will be my second round from the VA. Sure enough, got a call from Veterans Evaluation Service, who advised that the VA had contracted them to do my C&P examinations and to do bloodwork. Looks I'll be heading to Houston for the examinations and Beaumont for a blood draw and CBC. (They used VES on me last time too.) Keep in mind, I've been through a prior round of C&P examinations, but this is the first time with a CBC blood draw, and I have on file an independent medical examination and opinion report from the Ellis Clinic and an IMO from my oncologist of 17 years, along with a ton of medical records and SMRs. We'll see how this goes. I'll keep y'all posted on what went on. Looks like I have the examination on July 18 (Saturday) and the blood draw on the 21st. Mark
  23. Hey Everybody, I'm new to this forum and I see that this site is better then any lawyer or VSO. So I will lay my case out and see if anyone can answer these questions. I have looked high and low and haven't found answers to these questions. I am service connected with Tension Headache at 30% from an accident I was in while I was on active duty. I am 50% combined as of now and wanted to increase my combined to 70% by getting an increase of my headaches to 50%. I am positive that raising the headaches to 50% would make the 70% margin using the combined rating calculator. After achieving the 70% I would then apply for TDIU as I know the 70% number is required. I filed for an increase of my tension type headaches back in November 2014 which were currently 30%.I am looking to get them raised to 50% which is plausable as I have medical documentation and all the "requirements" that would give me the 50%. I did not use any outside representation and laid out all the evidence that would help me using E benefits. I received my answer 7 months later this June 2015. The rating letter came back and surprisingly said in so many words "We granted an increase of your headaches to 50% from the time of the Compensation and Pension claim in November 2014 to the time of the Compensation and Pension exam in June. After the compensation exam you will pushed back down to 30%. We will give you back pay as a 50% recipient from the time the claim started but we are moving you back to 30% after the exam took place. Now I know that I didn't say anything wrong or stupid in that exam. The examiner must of put wrong information in the claim or something because up until that point and today my headaches are still just as bad as they were when I put the claim in 7 months ago. With that being said....Do I appeal it? or would that make them reopen up the files and maybe try to take away other ratings. They must see all the evidence I turned in as being 50% headaches and they even agreed with it but then changed it back on the date of the exam. I am very confident If I appeal it I will win back that 50% headache percentage. If I appeal it I will then get that 70% combined number which can than in turn make me eligible for TDIU. Should I appeal the headaches, get the 70% and then apply for TDIU by appealing the new 70% number? Or should I appeal the headaches 30% decision then start a whole new claim for TDIU after they grant me the 70% combined Or should I appeal this decision and try to get TDIU now? Can I do that? Or would the TDIU claim be started from the time I put in for that rather then back to that november day I originally put in for the increase. Should I try to get the highest schedular rating I can before jumping into the TDIU boat in case I am able to work in the future and then they would drop me back to the 70% instead of this 50%. Can I go to school using my Post 911 GI bill if I recieve TDIU? If I am going to school will the VA ask about that on the application for TDIU and do they look down on that? If they do I will hold off on going to school until the application has been turned in. Should I get a lawyer who generally takes 30% of the back pay as they have a 95% success rate or do I also do this myself again? The lawyer said he is confident he can get me P&T. If I get 100% TDIU and stay unemployed is it hard to keep? If I take the do it yourself approach how can I know which IME is best for me to use? and the proper steps to take in order? As I said I looked at a 7 month turn around time for my increase. Are you seeing appeals going faster now after the scandals or still 2-5 years.Would my 7 month turn around time be an indication that my appeal would go pretty quickly? It seems like appeals are harder to get then new claims. I am married and have 5 children. per TDIU On the "below the poverty line" does that mean for me personally or me with a household of 7. Because the numbers are significantly different. Myself is rooughly below $12,000 and 7 in the family is below $36,000 per the poverty line government website. Thanks So Much Joe USMC
  24. I just finish my psych C&P exam. After I finished the doctor stated I must be scheduled for a "Complete Psych Test"...Which will take 3 to 4 hrs. Taking this type of test is this normal after a psych C&P exam? What exactly is a "Complete Psych Test" Should I be worried?
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