I recently had my C & P exam by a VA psychologist, and downloaded it
from My healthevet.
Note: For over 40 years, I kept to myself most of the traumatic Vietnam combat related experiences, especially the MST. I never reported the MST while in the RVN to Military, later to the VA, nor any civilian doctors. I kept the MST violations internally, never informing my wife until 2014 when seeking VA mental health treatment. I am still continuing MH counseling from the VA.
It appears the Opinions (NEXUS) by the C & P examiner are favorable, yese's for both PTSD Combat and MST, and Service Connected.
However, I do not agree with the Rating given for
"Occupational and social impairment " (30%)
I realize that other factors beside the C & P are use for the overall ratings.
Any educated guesses on what Rating might be given by the Rating person based on the C & P below? Combined Ratings ?
Below is about 98% of the actual C & P Report by the VA psychologist. Slight edits were made to the for clarity or anominity.
_______
Initial Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
* Internal VA or DoD Use Only *
Name of patient/Veteran: XXXXX
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 (F43.10)
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Posttraumatic Stress
Disorder ICD code: 309.81 (F43.10)
Mental Disorder Diagnosis #2: Alcohol Use Disorder
ICD code: 305.00 (F10.10)
b. Medical diagnoses relevant to the understanding or
management of the Mental Health Disorder (to include TBI):
deferred to medical providers
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?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no, provide reason that it is not possible to
differentiate what portion of each symptom is attributable to each
diagnosis and discuss
whether there is any clinical association between
these diagnoses:
The symptoms of each disorder overlap and occur
in a concurrent and
reciprocal relationship. It is not possible to
accurately separate
them without resorting to mere speculation.
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)
[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?
[ ] Yes [X] No [ ] No other mental disorder has
been diagnosed
If no, provide reason that it is not possible to
differentiate what portion of the indicated level of occupational
and social impairment
is attributable to each diagnosis:
The symptoms of each disorder overlap and occur
in a concurrent and
reciprocal relationship. It is not possible to
accurately separate
the impairments without resorting to mere
speculation.
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?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not
included in the
Veteran's VA claims file: recent medical records
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
[ ] Other:
b. Was pertinent information from collateral sources
reviewed?
[X] Yes [ ] No
If yes, describe:
cfile, medical records
2. History
----------
a. Relevant Social/Marital/Family history (pre-military,
military, and post-military):
He lives with his wife of 35 + years. He reports
their relationship has
had discord but he states they are currently getting
along "fine." He
reports increased agitation at home. He reports he
prefers to stay
around the house but they eventually enjoy going out
to organized
activities together at their senior community. They
attend dances. He
reports he also enjoys watching television and going
for walks. He
also enjoys running
He reports his relationship with his children is
"pretty good." He has a
friend from his community. He enjoys playing a
dominos game with
another couple once a week.
b. Relevant Occupational and Educational history (premilitary,
military, and post-military):
He last worked in 2002. He reports he applied for
social security
disability during 2002.(when 54 years old.)
He had been working for a college in CA as an administrator. He had been working for them for 2 years. He states he was
terminated related to
budget cuts. He states he perceives he was fired
for whistle blowing
on the President of the School who he states had
misapropriated funds.
Prior to that he was unemployed for 3 years. Prior
to working for another university as an assistant finance
controller for 3.5 years.
He states he was terminated due to poor performance.
He states he percieves he was terminated again related to whistle
blowing. He states he had reports to management that another
employee had not completed their job correctly and he perceives the
administration was
more loyal to the other employee. He attended
college and obtained a bachelors degree in business in 197x.
He served IN … from JUN of 1968 until MAR of 1970. His job was ….
He was honorably discharged at the rank of E4.
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and postmilitary):
He sought treatment at the ….CBOC during FEB of 2014. His diagnosis
at that time was Major Depressive Disorder, Anxiety
Disorder NOS, ADHD, and rule out PTSD.
He continued to received treatment.
During 2014 the diagnoses of PTSD and Alcohol Use Disorder were added. He is prescribed bupropion for psych symptoms.
d. Relevant Legal and Behavioral history (pre-military,
military, and post-military): denied
e. Relevant Substance abuse history (pre-military,
military, and post-military):
He reports he uses alcohol 2 days/week and drinks 4
drinks per sitting.
He states he has a history of excessive alcohol use
but in 2003 he
quit drinking alcohol after attending an alcohol
rehab program. He began drinking again in 2009 and has been moderation drinking. He
reports prior to 2003 he was drinking 10 beers per
day for 30 years.
He reports during his military service he used
amphetamine, alcohol,
and cannabis. He states he has not used cannabis or
amphetamine for 40 years.
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 postmilitary):
a. Stressor #1: He served in Vietnam. He witnessed a
plane crash with loss of life. There were episodes of incoming rounds.
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: He reports two incidents of MST. One of
suspected sodomy
while he was passed out and another of non-
consensual oral sex.
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:
it is related to MST
Is the stressor related to personal assault, e.g.
military sexual trauma?
[X] Yes [ ] No
If yes, please describe the markers that may
substantiate the stressor.
Service treatment records confirm service in Chu Lai from 68-69;
Complaints of "thinking bad" and feeling tense, thoughts of
going UA; c/o frequent
trouble sleeping and nervous trouble after 16
months of service.
Military Personnel File notes a decrease in
performance scores in March of 1969 and contains letter
from veteran noting that he does not
feel proud to
be in the uniform after his tour in RVN.
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] Directly experiencing the traumatic event(s)
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).
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
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] Markedly diminished interest or participation in
Significant activities.
X] Feelings of detachment or estrangement from others.
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] Hypervigilance.
[X] Exaggerated startle response.
[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
[X] Stressor #2
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
[X] Disturbances of motivation and mood
6. Behavioral Observations
--------------------------
Patient is oriented to all spheres. Patient's affect is
congruent with
stated mood and symptoms. Veteran was relatively calm
and responsive.
Speech is of normal rhythm and content. Veteran
maintained focus on topics
and responded appropriately to questions. There is no
evidence of a formal
thought disorder. Insight and judgment were grossly
intact. Active suicidal
ideation, planning, and intent was denied. Protective
factors were identified.
7. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to
PTSD (and other
mental disorders) that are not listed above?
[X] Yes [ ] No
If yes, describe: there is agitation without behavioral aggression.
8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
9. Remarks, (including any testing results) if any
Question
fatheryabueloDE9
I recently had my C & P exam by a VA psychologist, and downloaded it
from My healthevet.
Note: For over 40 years, I kept to myself most of the traumatic Vietnam combat related experiences, especially the MST. I never reported the MST while in the RVN to Military, later to the VA, nor any civilian doctors. I kept the MST violations internally, never informing my wife until 2014 when seeking VA mental health treatment. I am still continuing MH counseling from the VA.
It appears the Opinions (NEXUS) by the C & P examiner are favorable, yese's for both PTSD Combat and MST, and Service Connected.
However, I do not agree with the Rating given for
"Occupational and social impairment " (30%)
I realize that other factors beside the C & P are use for the overall ratings.
Any educated guesses on what Rating might be given by the Rating person based on the C & P below? Combined Ratings ?
Below is about 98% of the actual C & P Report by the VA psychologist. Slight edits were made to the for clarity or anominity.
_______
Initial Post Traumatic Stress Disorder (PTSD)
Disability Benefits Questionnaire
* Internal VA or DoD Use Only *
Name of patient/Veteran: XXXXX
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 (F43.10)
2. Current Diagnoses
--------------------
a. Mental Disorder Diagnosis #1: Posttraumatic Stress
Disorder ICD code: 309.81 (F43.10)
Mental Disorder Diagnosis #2: Alcohol Use Disorder
ICD code: 305.00 (F10.10)
b. Medical diagnoses relevant to the understanding or
management of the Mental Health Disorder (to include TBI):
deferred to medical providers
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?
[ ] Yes [X] No [ ] Not applicable (N/A)
If no, provide reason that it is not possible to
differentiate what portion of each symptom is attributable to each
diagnosis and discuss
whether there is any clinical association between
these diagnoses:
The symptoms of each disorder overlap and occur
in a concurrent and
reciprocal relationship. It is not possible to
accurately separate
them without resorting to mere speculation.
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)
[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?
[ ] Yes [X] No [ ] No other mental disorder has
been diagnosed
If no, provide reason that it is not possible to
differentiate what portion of the indicated level of occupational
and social impairment
is attributable to each diagnosis:
The symptoms of each disorder overlap and occur
in a concurrent and
reciprocal relationship. It is not possible to
accurately separate
the impairments without resorting to mere
speculation.
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?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not
included in the
Veteran's VA claims file: recent medical records
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
[ ] Other:
b. Was pertinent information from collateral sources
reviewed?
[X] Yes [ ] No
If yes, describe:
cfile, medical records
2. History
----------
a. Relevant Social/Marital/Family history (pre-military,
military, and post-military):
He lives with his wife of 35 + years. He reports
their relationship has
had discord but he states they are currently getting
along "fine." He
reports increased agitation at home. He reports he
prefers to stay
around the house but they eventually enjoy going out
to organized
activities together at their senior community. They
attend dances. He
reports he also enjoys watching television and going
for walks. He
also enjoys running
He reports his relationship with his children is
"pretty good." He has a
friend from his community. He enjoys playing a
dominos game with
another couple once a week.
b. Relevant Occupational and Educational history (premilitary,
military, and post-military):
He last worked in 2002. He reports he applied for
social security
disability during 2002.(when 54 years old.)
He had been working for a college in CA as an administrator. He had been working for them for 2 years. He states he was
terminated related to
budget cuts. He states he perceives he was fired
for whistle blowing
on the President of the School who he states had
misapropriated funds.
Prior to that he was unemployed for 3 years. Prior
to working for another university as an assistant finance
controller for 3.5 years.
He states he was terminated due to poor performance.
He states he percieves he was terminated again related to whistle
blowing. He states he had reports to management that another
employee had not completed their job correctly and he perceives the
administration was
more loyal to the other employee. He attended
college and obtained a bachelors degree in business in 197x.
He served IN … from JUN of 1968 until MAR of 1970. His job was ….
He was honorably discharged at the rank of E4.
c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and postmilitary):
He sought treatment at the ….CBOC during FEB of 2014. His diagnosis
at that time was Major Depressive Disorder, Anxiety
Disorder NOS, ADHD, and rule out PTSD.
He continued to received treatment.
During 2014 the diagnoses of PTSD and Alcohol Use Disorder were added. He is prescribed bupropion for psych symptoms.
d. Relevant Legal and Behavioral history (pre-military,
military, and post-military): denied
e. Relevant Substance abuse history (pre-military,
military, and post-military):
He reports he uses alcohol 2 days/week and drinks 4
drinks per sitting.
He states he has a history of excessive alcohol use
but in 2003 he
quit drinking alcohol after attending an alcohol
rehab program. He began drinking again in 2009 and has been moderation drinking. He
reports prior to 2003 he was drinking 10 beers per
day for 30 years.
He reports during his military service he used
amphetamine, alcohol,
and cannabis. He states he has not used cannabis or
amphetamine for 40 years.
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 postmilitary):
a. Stressor #1: He served in Vietnam. He witnessed a
plane crash with loss of life. There were episodes of incoming rounds.
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: He reports two incidents of MST. One of
suspected sodomy
while he was passed out and another of non-
consensual oral sex.
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:
it is related to MST
Is the stressor related to personal assault, e.g.
military sexual trauma?
[X] Yes [ ] No
If yes, please describe the markers that may
substantiate the stressor.
Service treatment records confirm service in Chu Lai from 68-69;
Complaints of "thinking bad" and feeling tense, thoughts of
going UA; c/o frequent
trouble sleeping and nervous trouble after 16
months of service.
Military Personnel File notes a decrease in
performance scores in March of 1969 and contains letter
from veteran noting that he does not
feel proud to
be in the uniform after his tour in RVN.
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] Directly experiencing the traumatic event(s)
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).
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
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] Markedly diminished interest or participation in
Significant activities.
X] Feelings of detachment or estrangement from others.
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] Hypervigilance.
[X] Exaggerated startle response.
[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
[X] Stressor #2
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
[X] Disturbances of motivation and mood
6. Behavioral Observations
--------------------------
Patient is oriented to all spheres. Patient's affect is
congruent with
stated mood and symptoms. Veteran was relatively calm
and responsive.
Speech is of normal rhythm and content. Veteran
maintained focus on topics
and responded appropriately to questions. There is no
evidence of a formal
thought disorder. Insight and judgment were grossly
intact. Active suicidal
ideation, planning, and intent was denied. Protective
factors were identified.
7. Other symptoms
-----------------
Does the Veteran have any other symptoms attributable to
PTSD (and other
mental disorders) that are not listed above?
[X] Yes [ ] No
If yes, describe: there is agitation without behavioral aggression.
8. Competency
-------------
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [ ] No
9. Remarks, (including any testing results) if any
--------------------------------------------------
No remarks provided.
NOTE: VA may request additional medical information,
including additional
examinations if necessary to complete VA's review of the
Veteran's
application.
**************************************************************************
**
Medical Opinion
Disability Benefits Questionnaire
Name of patient/Veteran: xxxxx
Indicate method used to obtain medical information to
complete this document:
[ ] 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
[X] 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: recent medical records
MEDICAL OPINION SUMMARY
-----------------------
RESTATEMENT OF REQUESTED OPINION:
a. Opinion from general remarks: The Veteran is claiming
service connection for PTSD.
Please evaluate and
provide an opinion as to whether or not the veteran has a
current diagnosis of posttraumatic stress disorder that is related to his
conceded stressor of fear of hostile military activity.
If a diagnosis of PTSD is made, the examiner needs to
determine if the
Veteran's claimed stressor is related to the Veteran's
fear of in-service
hostile military or terrorist activity. The current
worksheet/template is
otherwise adequate to encompass the new regulation. The
initial PTSD
examination is to be conducted by a VA psychiatrist or psychologist.
"Fear of hostile military or terrorist activity" means
that a Veteran
experienced, witnessed, or was confronted with an event
or circumstances
that involved actual or threatened death or serious
injury, or a threat to
the physical integrity of the Veteran or others and the
Veteran's response
to the event or circumstances involved a psychological or
psychophysiological
state of fear, helplessness, or horror. The
event or
circumstances include, but are not limited to, the
following:
(1) Actual or potential improvised explosive device;
(2) Vehicle-embedded explosive device;
(3) Incoming artillery, rocket, or mortar fire;
(4) Small arms fire, including suspected sniper fire; or
(5) Attack upon friendly aircraft.
***IF NO TO OPINION ABOVE, PLEASE PROVIDE AN OPINION
REGARDING PSTD DUE TO MST BELOW - THANK YOU***
MST OPINION - Please review the veteran's entire claims
file and medical
records and provide an opinion as to whether it is at
least as likely as not
that the VETERAN'S RECORDS SUPPORT THE OCCURRENCE of a
military sexual assault.
Please do not provide opinion #2, unless you have
provided opinion #1.
Opinion #2
If YES to opinion #1, please provide an opinion as to
whether the veteran's
current mental health condition is at least as likely as
not related to the
military sexual assault.
Opinion #3
If NO to opinion #1, please provide an opinion as to
whether it is at least
as likely as not that the veteran's current mental health
condition had its
onset in military service. If you find that this
condition pre-existed the
veteran's military service, please indicate if the
treatment during service
shows this condition was aggravated beyond it's normal
level of progression
by military service.
Rationale must be provided in the appropriate section.
If more than one mental disorder is diagnosed please
comment on their
relationship to one another and, if possible, please
state which symptoms are attributed to each disorder.
b. Indicate type of exam for which opinion has been
requested: Initial PTSD
TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR
DIRECT SERVICE CONNECTION ]
a. The condition claimed was at least as likely as not
(50% or greater probability) incurred in or caused by the claimed inservice injury, event or illness.
c. Rationale: To reiterate, the veterans PTSD is MOST
LIKELY related to both his fear of hostile military and terrorist activity as
well as to MST.
The record MOST LIKELY supports the occurance of MST.
Finally, the veterans symptoms did MOST LIKELY have onset while in
the military.
Opinion is based on clinical experience and research, clinical interview data, DSM5 criteria,
behavioral observation, and supporting service and
medical records.
*********************************************************
****************
xxxxxxx, PSY.D.
STAFF PSYCHOLOGIST, C&P
Signed: 03/xx/2015 07:36
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Berta
What do you get the SSDI for? If it is solely for what you are getting SCed for, then the 30% is WAY too low. Does VA have your SSDI records?
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