VA Form 21-0960P-3 Review Post Traumatic Stress Disorder (PTSD) Disability

OMB Control No. 2900-0779
Respondent Burden: 30 minutes

REVIEW POST TRAUMATIC STRESS DISORDER (PTSD)
DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE
PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION
BEFORE COMPLETING THIS FORM.
NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

Your patient is applying to the U. S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this
questionnaire as part of their evaluation in processing the Veteran's claim. Please note that this questionnaire is for disability evaluation, not for treatment
purposes.
NOTE: If the Veteran experiences a mental health emergency during the interview, please terminate the interview and obtain help, using local resources as
appropriate. You may also contact the Veterans Crisis Line at 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the Veteran to emergency
care.
The following health care providers can perform REVIEW examinations for PTSD: a board-certified or board-eligible psychiatrist; a licensed doctorate-level
psychologist; a doctorate-level mental health provider under the close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level
psychologist; a psychiatry resident under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist; a clinical or
counseling psychologist completing a one-year internship or residency (for purposes of a doctorate-level degree) under close supervision of a board-certified or boardeligible psychiatrist or licensed doctorate-level psychologist; or a licensed clinical social worker (LCSW), a nurse practitioner, a clinical nurse specialist, or a physician
assistant, under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist.
SECTION I: DIAGNOSIS
1. DIAGNOSTIC SUMMARY

NOTE: This section should be completed based on the current examination and clinical findings.
1. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH PTSD?
YES

NO (If "Yes," continue to complete this Questionnaire)

(If no diagnosis of PTSD, and the veteran has another Axis I and/or II diagnosis, then continue to complete this Questionnaire and/or VA Form
21-0960P-1, Eating Disorders Disability Benefits Questionnaire)

2. CURRENT DIAGNOSES
2A. LIST CURRENT DIAGNOSES
DIAGNOSIS #1
ICD CODE:

INDICATE THE AXIS CATEGORY:

AXIS I

AXIS II

INDICATE THE AXIS CATEGORY:

AXIS I

AXIS II

INDICATE THE AXIS CATEGORY:

AXIS I

AXIS II

INDICATE THE AXIS CATEGORY:

AXIS I

AXIS II

COMMENTS, IF ANY:
DIAGNOSIS #2
ICD CODE:
COMMENTS, IF ANY:
DIAGNOSIS #3
ICD CODE:
COMMENTS, IF ANY:
DIAGNOSIS #4
ICD CODE:
COMMENTS, IF ANY:
IF ADDITIONAL DIAGNOSES, DESCRIBE USING ABOVE FORMAT:

2B. AXIS III - MEDICAL DIAGNOSES (TO INCLUDE TBI):
ICD CODE:
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DEC 2010

21-0960P-3

COMMENTS, IF ANY:

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2. CURRENT DIAGNOSES (Continued)
2C. AXIS IV - PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS (DESCRIBE, IF ANY):

2D. AXIS V - CURRENT GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCORE:
COMMENTS, IF ANY:

3. DIFFERENTIATION OF SYMPTOMS
3A. DOES THE VETERAN HAVE MORE THAN ONE MENTAL DISORDER DIAGNOSED?
YES

NO

(If "Yes," complete Item 3B)

3B. IS IT POSSIBLE TO DIFFERENTIATE WHAT SYMPTOM(S) IS/ARE ATTRIBUTABLE TO EACH DIAGNOSIS?
YES

NO

NOT APPLICABLE

(If "No," provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis)

(If "Yes," list which symptoms are attributable to each diagnosis)

3C. DOES THE VETERAN HAVE A DIAGNOSED TRAUMATIC BRAIN INJURY (TBI)?
YES

NO

NOT SHOWN IN RECORDS REVIEWED

(If "Yes," complete Item 3D)

Comments, if any:

3D. IS IT POSSIBLE TO DIFFERENTIATE WHAT SYMPTOM(S) IS/ARE ATTRIBUTABLE TO EACH DIAGNOSIS?
YES

NO

NOT APPLICABLE

(If "No," provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis)

(If "Yes," list which symptoms are attributable to each diagnosis)

4. OCCUPATIONAL AND SOCIAL IMPAIRMENT
4A. 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 MENTAL DISORDER DIAGNOSIS
A MENTAL CONDITION HAS BEEN FORMALLY DIAGNOSED, BUT SYMPTONS ARE NOT SEVERE ENOUGH EITHER TO INTERFERE WITH OCCUPATIONAL
AND SOCIAL FUNCTIONING OR TO REQUIRE CONTINUOUS MEDICATION
OCCUPATIONAL AND SOCIAL IMPAIRMENT DUE TO MILD OR TRANSIENT SYMPTONS WHICH DECREASE WORK EFFICIENCY AND ABILITY TO PERFORM
OCCUPATIONAL TASKS ONLY DURING PERIODS OF SIGNIFICANT STRESS, OR SYMPTOMS CONTROLLED BY MEDICATION
OCCUPATIONAL AND SOCIAL IMPAIRMENT WITH OCCASIONAL DECREASE IN WORK EFFICIENCY AND INTERMITTENT PERIODS OF INABILITY TO PERFORM
OCCUPATIONAL TASKS, ALTHOUGH GENERALLY FUNCTIONING SATISFACTORILLY, WITH NORMAL ROUTINE BEHAVIOR, SELF-CARE AND CONVERSATION
OCCUPATIONAL AND SOCIAL IMPAIRMENT WITH REDUCED RELIABILITY AND PRODUCTIVITY
OCCUPATIONAL AND SOCIAL IMPAIRMENT WITH DEFICIENCIES IN MOST AREAS, SUCH AS WORK, SCHOOL, FAMILY RELATIONS, JUDGMENT, THINKING
AND/OR MOOD
TOTAL OCCUPATIONAL AND SOCIAL IMPAIRMENT
4B. 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

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)

(If "Yes," list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis)

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4. OCCUPATIONAL AND SOCIAL IMPAIRMENT (Continued)
4C. 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

NO DIAGNOSIS OF TBI

(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)

(If "Yes," list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis)

SECTION II - CLINICAL FINDINGS
1. EVIDENCE REVIEW
IF ANY RECORDS (EVIDENCE) WERE REVIEWED, PLEASE LIST

2. RECENT HISTORY (SINCE PRIOR EXAM)
2A. RELEVANT SOCIAL/MARITAL/FAMILY HISTORY

2B. RELEVANT OCCUPATIONAL AND EDUCATIONAL HISTORY

2C. RELEVANT MENTAL HEALTH HISTORY, TO INCLUDE PRESCRIBED MEDICATIONS AND FAMILY MENTAL HEALTH

2D. RELEVANT LEGAL AND BEHAVIORAL HISTORY

2E. RELEVANT SUBSTANCE ABUSE HISTORY

2F. SENTINEL EVENT(S) (OTHER THAN STRESSORS)

2G. OTHER (If any)

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3. PTSD DIAGNOSTIC CRITERIA

NOTE: Please check criteria used for establishing the current PTSD diagnosis. The diagnostic criteria for PTSD, referred to as Criteria A-F, are
from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).
CRITERION A: The Veteran has been exposed to a traumatic event where both of the following were present
The Veteran experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of
self or others.
The Veteran's response involved intense fear, helplessness or horror.
No exposure to a traumatic event.

CRITERION B: The traumatic event is persistently re-experienced in 1 or more of the following ways:
Recurrent and distressing recollections of the event, including images, thoughts or perceptions
Recurrent distressing dreams of the event
Acting or feeling as if the traumatic event were recurring; this includes a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes,
including those that occur on awakening or when intoxicated
Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
The traumatic event is not persistently re-experienced

CRITERION C: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness
(not present before the trauma), as indicated by 3 or more of the following:
Efforts to avoid thoughts, feelings or conversations associated with the trauma
Efforts to avoid activities, places or people that arouse recollections of the trauma
Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant activities
Feeling of detachment or estrangement from others
Restricted range of affection (e.g., unable to have loving feelings)
Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children or a normal life span)
No persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness

CRITERION D: Persistent symptoms of increased arousal, not present before the trauma, as indicated by 2 or more of the following:
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilence
Exaggerated startle response
No persistent symptoms of increased arousal

CRITERION E: Duration of symptoms
The duration of the symptoms described in Criteria B, C and D is more than 1 month
The duration of the symptoms described in Criteria B, C and D is less than 1 month
Veteran does not meet full criteria for PTSD

CRITERION F: Clinically significant distress or impairment
The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The PTSD symptoms described above do NOT cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Veteran does not meet full criteria for PTSD
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4. SYMPTOMS
FOR VA RATING PURPOSES, CHECK ALL SYMPTOMS THAT APPLY TO THE VETERAN'S DIAGNOSES
Depressed mood
Anxiety
Suspiciousness
Panic attacks that occur weekly or less often
Panic attacks more than once a week
Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively
Chronic sleep impairment
Mild memory loss, such as forgetting names, directions or recent events
Impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks
Memory loss for names of close relatives, own occupation, or own name
Flattened affect
Circumstantial, circumlocutory or stereotyped speech
Speech intermittently illogical, obscure, or irrelevant
Difficulty in understanding complex commands
Impaired judgment
Impaired abstract thinking
Gross impairment in thought processes or communication
Disturbances of motivation and mood
Difficulty in establishing and maintaining effective work and social relationships
Difficulty adapting to stressful circumstances, including work or a worklike setting
Inability to establish and maintain effective relationships
Suicidal ideation
Obsessional rituals which interfere with routine activities
Impaired impulse control, such as unprovoked irritability with periods of violence
Spatial disorientation
Persistent delusions or hallucinations
Grossly inappropriate behavior
Persistent danger of hurting self or others
Neglect of personal appearance and hygiene
Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene
Disorientation to time or place

5. OTHER SYMPTOMS
DOES THE VETERAN HAVE ANY OTHER SYMPTOMS ATTRIBUTABLE TO PTSD (AND OTHER MENTAL DISORDERS) THAT ARE NOT LISTED ABOVE?
YES

NO

(If "Yes," describe)

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6. COMPETENCY
IS THE VETERAN CAPABLE OF MANAGING HIS OR HER FINANCIAL AFFAIRS?
YES

NO

(If "No," explain)

7. REMARKS (If any)

8. PSYCHIATRIST/PSYCHOLOGIST CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
8A. PSYCHIATRIST/PSYCHOLOGIST SIGNATURE AND TITLE

8D. PSYCHIATRIST/PSYCHOLOGIST PHONE AND
FAX NUMBERS

8B. PSYCHIATRIST/PSYCHOLOGIST PRINTED NAME

8E. PSYCHIATRIST/PSYCHOLOGIST LICENSE
NUMBER

8C. DATE SIGNED

8F. PSYCHIATRIST/PSYCHOLOGIST ADDRESS

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

IMPORTANT - PSYCHIATRIST/PSYCHOLOGIST send the completed form to
(VA Regional Office FAX No.)

NOTE - A list of VA Regional Office FAX Numbers can be found at www.vba.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
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Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
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VA FORM 21-0960P-3, DEC 2010

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