Name of patient/Veteran: XXXXX, XXXX, XXXXX Indicate method used to obtain medical information to complete this document:
[X] Review of available records (without in‐person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence.
[ ] Review of available records in conjunction with a telephone interview with the Veteran (without in‐person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence.
[ ] Examination via approved video telehealth
[ ] In‐person examination Evidence review
Was the Veteran's VA claims file reviewed? Yes
If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: N/A
MEDICAL OPINION SUMMARY ‐‐‐RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks:
OPINION: The VAMC examination completed on X Date shows a diagnosis of Major Depressive Disorder, Recurrent , Moderate with Anxious Distress. The Examiner opined that the condition was less likely than not related to the Veteran's military service. However, the Veteran has submitted a medical opinion from VAMC physicians, which state that the Veteran's mental health condition is related to his military service. Please review the cited evidence and state if it is at least as likely as not that the Veteran's currently diagnosed mental health condition is related to his military service.
If so, what impact does the condition have on the Veteran's ability to obtain and/or maintain gainful employment?
b. Indicate type of exam for which opinion has been requested: INITIAL PTSD EXAM TYPE OF MEDICAL OPINION PROVIDED:
[ OPINION REGARDING CONFLICTING MEDICAL EVIDENCE ]
I have reviewed the conflicting medical evidence and am providing the following opinion: Opinion & Rationale: According the reports by Dr's., Veteran PTSD symptoms and Major Depressive Disorder are related to his military experiences. The Veteran's PTSD reflects moderately impairment in symptoms of, "intrusive experiences, hyperarousal, attempts at experiential or behavioral avoidance, negative alterations in mood and cognition" related trauma. For this Veteran, there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational task are limitations to employment. Although, there may be limitations in his ability to maintain employment, the Veteran's moderate symptoms do not completely prevent him from engaging in gainful employment with physical or sedentary work.
Psychologist PhD
Signed
***I also have a letter from my Independent Living Counselor stating I’m unemployable and unattainable by the VA VOCREHAB so that’s why I’m enrolled into the ILP program
***Would I get a 30% or a 50% PTSD rating? I cannot really tell by looking thru the rating schedule.
Thank you for looking over it and giving any advice.
Question
saints13
Medical Opinion Disability Benefits Questionnaire
Name of patient/Veteran: XXXXX, XXXX, XXXXX Indicate method used to obtain medical information to complete this document:
[X] Review of available records (without in‐person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence.
[ ] Review of available records in conjunction with a telephone interview with the Veteran (without in‐person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence.
[ ] Examination via approved video telehealth
[ ] In‐person examination Evidence review
Was the Veteran's VA claims file reviewed? Yes
If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: N/A
MEDICAL OPINION SUMMARY ‐‐‐RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks:
OPINION: The VAMC examination completed on X Date shows a diagnosis of Major Depressive Disorder, Recurrent , Moderate with Anxious Distress. The Examiner opined that the condition was less likely than not related to the Veteran's military service. However, the Veteran has submitted a medical opinion from VAMC physicians, which state that the Veteran's mental health condition is related to his military service. Please review the cited evidence and state if it is at least as likely as not that the Veteran's currently diagnosed mental health condition is related to his military service.
If so, what impact does the condition have on the Veteran's ability to obtain and/or maintain gainful employment?
b. Indicate type of exam for which opinion has been requested: INITIAL PTSD EXAM TYPE OF MEDICAL OPINION PROVIDED:
[ OPINION REGARDING CONFLICTING MEDICAL EVIDENCE ]
I have reviewed the conflicting medical evidence and am providing the following opinion: Opinion & Rationale: According the reports by Dr's., Veteran PTSD symptoms and Major Depressive Disorder are related to his military experiences. The Veteran's PTSD reflects moderately impairment in symptoms of, "intrusive experiences, hyperarousal, attempts at experiential or behavioral avoidance, negative alterations in mood and cognition" related trauma. For this Veteran, there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational task are limitations to employment. Although, there may be limitations in his ability to maintain employment, the Veteran's moderate symptoms do not completely prevent him from engaging in gainful employment with physical or sedentary work.
Psychologist PhD
Signed
***I also have a letter from my Independent Living Counselor stating I’m unemployable and unattainable by the VA VOCREHAB so that’s why I’m enrolled into the ILP program
***Would I get a 30% or a 50% PTSD rating? I cannot really tell by looking thru the rating schedule.
Thank you for looking over it and giving any advice.
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