I am having terrible luck with VA C&P exams. Any guess as to my rating?
SC diagnosed and treated by Psychiatrist while active duty
Here are highlights of PTSD DBQ.
Marked:
10% [X] Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication
But examiner checked these symptoms:
[X] Depressed mood [X] Anxiety [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] Difficulty in adapting to stressful circumstances, including work or a worklike setting
———-Redacted DBQ below—————
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
b. Medical diagnoses relevant to the understanding or management of the
mental health disorder (to include TBI): see Veteran's medical record for
pertinent medical conditions
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes [X] No
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 due to mild or transient symptoms
which decrease work efficiency and ability to perform occupational
tasks only during periods of significant stress, or; symptoms
controlled by medication
b. For the indicated occupational and social impairment, is it possible to
differentiate which impairment is caused by each mental disorder?
[ ] Yes [ ] No [X] Not Applicable (N/A)
c. If a diagnosis of TBI exists, is it possible to differentiate which
occupational and social impairment indicated above is caused by the TBI?
[ ] Yes [ ] No [X] Not Applicable (N/A)
SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder
[X] CPRS
2. History
Post-Military: N/A
d. Relevant legal and behavioral history (pre-military, military, and
post-military):
Veteran denied.
e. Relevant substance abuse history (pre-military, military, and
post-military):
Veteran denied
d.
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.
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
---------------------------
Note: Please check criteria used for establishing the current PTSD
diagnosis.
Do NOT mark symptoms below that are clearly not attributable to the
Criterion
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 Criterion 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 violence, in one or more of the following ways:
[X] Directly experiencing the traumatic event(s)
[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] Intense or prolonged psychological distress at exposure
To internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
Criterion 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,
of feelings about or closely associated with the traumatic
event(s).
Criterion 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 negative emotional state (e.g., fear, horror,
anger, guilt, or shame).
[X] Markedly diminished interest or participation in
significant activities.
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] 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
[X] Depressed mood [X] Anxiety [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] Difficulty in adapting to stressful circumstances, including work or a worklike settingrk and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting
6. Behavioral Observations
--------------------------
Veteran was cooperative during the examination.
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
--------------------------------------------------
No remarks provided.
Please use this DBQ to address 1151 requests, or other issues that are not
specifically addressed by specific DBQs such as Individual Unemployability
(UI).
Mental health - Separation Health Assessment
Disability Benefits Questionnaire
* Internal VA or DoD Use Only*
Was a DD Form 2807-1, Report of Medical History, completed by the
Service member and available for review at the time of this examination?
[x] Yes [] No [ ] N/A
Any changes to his/her health status since DD 2807-1 completed?
[ ] Yes[x] No[] N/A
(Proposed) Date of separation from active service: ETS June 2018
1. Medical record review
-------------------------
Was the Veteran's VA claims file reviewed?
[x] Yes [ ] No
2. Medical history (Review of Systems)
--------------------------------------
(Please follow format if more claims are being addressed)
PTSD SCREEN PC-PTSD
-------------------
In your life, have you ever had any experience that was so
frightening, horrible, or upsetting that, in the past month,
you:
1. Have had nightmares about it or thought about it when you
did
not want to?
[x] Yes []
2. Tried hard not to think about it or went out of your way to
avoid situations that reminded you of it?
[x] Yes [] No
3. Were constantly on guard, watchful, or easily startled?
[x] Yes [] No
4. Felt numb or detached from others, activities, or your
surroundings?
[x] Yes [] No
Depression screen: PHQ2
-----------------------
Over the past two weeks, how often have you been bothered by
Any of the following problems?
Little interest or pleasure in doing things.
[] 0 = Not at all [x] 1 = Several days [] 2 = More than half the days [] 3 = Nearly every day
Feeling down, depressed, or hopeless.
[] 0 = Not at all [x] 1 = Several days [] 2 = More than half
The days [ ] 3 = Nearly every day
Total Point Score: 2
Brief Suicide Risk Assessment
-----------------------------
- (Perform if score positive on Depression or PTSD screens)
Are you feeling hopeless about the present or future?
[] Yes [x] No
Have you had thoughts about taking your life - if yes - when
did you have these thoughts and do you have a plan to take your
life?
[x] Yes [x] No
Have you ever had a suicide attempt?
[ ] Yes [x] No
3. Physical Exam
-----------------
1. Psychiatric (Specify any personality deviation)
[ ] Normal [x] Abnormal [ ] Not examined
Question
Merlynda
I am having terrible luck with VA C&P exams. Any guess as to my rating?
SC diagnosed and treated by Psychiatrist while active duty
Here are highlights of PTSD DBQ.
Marked:
10%
[X] Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms
controlled by medication
But examiner checked these symptoms:
[X] Depressed mood [X] Anxiety
[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] Difficulty in adapting to stressful circumstances, including work or a worklike setting
———-Redacted DBQ below—————
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
b. Medical diagnoses relevant to the understanding or management of the
mental health disorder (to include TBI): see Veteran's medical record for
pertinent medical conditions
3. Differentiation of symptoms
------------------------------
a. Does the Veteran have more than one mental disorder diagnosed?
[ ] Yes [X] No
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 due to mild or transient symptoms
which decrease work efficiency and ability to perform occupational
tasks only during periods of significant stress, or; symptoms
controlled by medication
b. For the indicated occupational and social impairment, is it possible to
differentiate which impairment is caused by each mental disorder?
[ ] Yes [ ] No [X] Not Applicable (N/A)
c. If a diagnosis of TBI exists, is it possible to differentiate which
occupational and social impairment indicated above is caused by the TBI?
[ ] Yes [ ] No [X] Not Applicable (N/A)
SECTION II:
-----------
Clinical Findings:
------------------
1. Evidence Review
------------------
Evidence reviewed (check all that apply):
[X] VA e-folder
[X] CPRS
2. History
Post-Military: N/A
d. Relevant legal and behavioral history (pre-military, military, and
post-military):
Veteran denied.
e. Relevant substance abuse history (pre-military, military, and
post-military):
Veteran denied
d.
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.
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
---------------------------
Note: Please check criteria used for establishing the current PTSD
diagnosis.
Do NOT mark symptoms below that are clearly not attributable to the
Criterion
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 Criterion 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 violence, in one or more of the following ways:
[X] Directly experiencing the traumatic event(s)
[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] Intense or prolonged psychological distress at exposure
To internal or external cues that symbolize or resemble an
aspect of the traumatic event(s).
Criterion
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,
of feelings about or closely associated with the traumatic
event(s).
Criterion
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 negative emotional state (e.g., fear, horror,
anger, guilt, or shame).
[X] Markedly diminished interest or participation in
significant activities.
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] 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
[X] Depressed mood
[X] Anxiety
[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] Difficulty in adapting to stressful circumstances, including work or
a worklike settingrk and social
relationships
[X] Difficulty in adapting to stressful circumstances, including work or
a worklike setting
6. Behavioral Observations
--------------------------
Veteran was cooperative during the examination.
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
--------------------------------------------------
No remarks provided.
****************************************************************************
Miscellaneous
Disability Benefits Questionnaire
Please use this DBQ to address 1151 requests, or other issues that are not
specifically addressed by specific DBQs such as Individual Unemployability
(UI).
Mental health - Separation Health Assessment
Disability Benefits Questionnaire
* Internal VA or DoD Use Only*
Was a DD Form 2807-1, Report of Medical History, completed by the
Service member and available for review at the time of this examination?
[x] Yes [] No [ ] N/A
Any changes to his/her health status since DD 2807-1 completed?
[ ] Yes[x] No[] N/A
(Proposed) Date of separation from active service: ETS June 2018
1. Medical record review
-------------------------
Was the Veteran's VA claims file reviewed?
[x] Yes [ ] No
2. Medical history (Review of Systems)
--------------------------------------
1. Psychiatric:
[x] Yes[ ] No
#1. Claimed Condition: PTSD
Onset:
History:
Prognosis: Unknown.
#2. Claimed Condition:
Onset:
History:
Prognosis:
(Please follow format if more claims are being addressed)
PTSD SCREEN PC-PTSD
-------------------
In your life, have you ever had any experience that was so
frightening, horrible, or upsetting that, in the past month,
you:
1. Have had nightmares about it or thought about it when you
did
not want to?
[x] Yes []
2. Tried hard not to think about it or went out of your way to
avoid situations that reminded you of it?
[x] Yes [] No
3. Were constantly on guard, watchful, or easily startled?
[x] Yes [] No
4. Felt numb or detached from others, activities, or your
surroundings?
[x] Yes [] No
Depression screen: PHQ2
-----------------------
Over the past two weeks, how often have you been bothered by
Any of the following problems?
Little interest or pleasure in doing things.
[] 0 = Not at all [x] 1 = Several days [] 2 = More than half the days [] 3 = Nearly every day
Feeling down, depressed, or hopeless.
[] 0 = Not at all [x] 1 = Several days [] 2 = More than half
The days [ ] 3 = Nearly every day
Total Point Score: 2
Brief Suicide Risk Assessment
-----------------------------
- (Perform if score positive on Depression or PTSD screens)
Are you feeling hopeless about the present or future?
[] Yes [x] No
Have you had thoughts about taking your life - if yes - when
did you have these thoughts and do you have a plan to take your
life?
[x] Yes [x] No
Have you ever had a suicide attempt?
[ ] Yes [x] No
3. Physical Exam
-----------------
1. Psychiatric (Specify any personality deviation)
[ ] Normal [x] Abnormal [ ] Not examined
5. Diagnosis:
-------------
#1. Claimed condition: PTSD.
Diagnosis/Rationale: Veteran meets the DSM-5 diagnostic
criteria forPTSD
#2. Claimed condition:
Diagnosis/Rationale:
(for additional Claim/diagnosis, please follow above format)
6. Remarks, if any:
-------------------
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