Initial PTSD Disability Benefits Questionnaire

INITIAL POST TRAUMATIC STRESS (PTSD)
DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT: This form is only for use by VHA and VBA staff and contract psychiatrists or psychologists.
NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

IMPORTANT - 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 VA Suicide Prevention Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the veteran to
emergency care.
NOTE - 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.

CRITERIA INFORMATION FOR PTSD EXAMINER
IMPORTANT: In order to conduct an initial examination for PTSD, the examiner must meet one of the following criteria: (1) be a board-certified or board-eligible
psychiatrist; (2) a licensed doctorate-level psychologist; (3) a doctorate-level mental health provider under the close supervision of a board-certified or board-eligible
psychiatrist or licensed doctorate-level psychologist; (4) a psychiatry resident under close supervision of a board-certified or board-eligible psychiatrist or licensed
doctorate-level psychologist; (5) or 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 board-eligible psychiatrist or licensed doctorate-level psychologist.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE A DIAGNOSIS OF PTSD THAT CONFORMS TO DSM IV CRITERIA?
YES

NO

(If "Yes," complete Item1B) (If "No," complete Item 1C)

1B. PROVIDE THE DATE OF DIAGNOSIS, ICD CODE, & FACILITY
ICD CODE-

DATE OF DIAGNOSIS

NAME OF DIAGNOSING FACILITY OR CLINICIAN

1C. PTSD NOT DIAGNOSED (Check all that apply)
VETERAN'S SYMPTOMS DO NOT MEET THE DIAGNOSTIC CRITERIA FOR PTSD UNDER DSM IV CRITERIA
VETERAN HAS ANOTHER AXIS I-IV DIAGNOSIS (If checked, list the Axis I-IV diagnosis and then complete the VA Form 21-0960P-2, Mental Health Disorder
Disability Benefits Questionnaire and/or the VA Form 21-0960P-1, Eating Disorder Disability Benefits Questionnaire in lieu of this questionnaire):
OTHER TRAUMA SPECTRUM DISORDER
VETERAN DOES NOT HAVE A MENTAL DISORDER THAT CONFORMS WITH DSM IV CRITERIA
OTHER (Describe)
1D. IF THERE IS A DIAGNOSIS OF PTSD, DOES THE VETERAN ALSO HAVE A NY OTHER AXIS I-IV DIAGNOSES?
YES

NO

(If "Yes," indicate additional diagnoses below)
MENTAL HEALTH DISORDER #1

(If checked, provide the ICD code
clinician
(If checked, indicate the Axis category):

, the date of the diagnosis
AXIS I

AXIS II

AXIS III

and the name of the diagnosing facility or
).
AXIS IV

(If checked, describe the condition and its relationship to PTSD):
MENTAL HEALTH DISORDER #2

(If checked, provide the ICD code
clinician
(If checked, indicate the Axis category):

, the date of the diagnosis
AXIS I

AXIS II

AXIS III

and the name of the diagnosing facility or
).
AXIS IV

(If checked, describe the condition and its relationship to PTSD):
MENTAL HEALTH DISORDER #3

(If checked, provide the ICD code
clinician
(If checked, indicate the Axis category):

, the date of the diagnosis
AXIS I

AXIS II

AXIS III

and the name of the diagnosing facility or
).
AXIS IV

(If checked, describe the condition and its relationship to PTSD):
(If additional diagnoses, describe using the above format):
VA FORM
DEC 2010

21-0960P-4

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SECTION II - DIAGNOSTIC CRITERIA
2. 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) (Check boxes next to symptoms below)

CRITERION A: The Veteran has been exposed to a traumatic event where both A and B were present
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
Veteran's response involved intense fear, helplessness or horror
No exposure to a traumatic event

CRITERION B: The traumatic event is persistently reexperienced 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 reexperienced

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 affect (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
No symptoms

CRITERION F: Clinically significant distress or impairment
The symptoms described above in Criteria B, C and D cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
The symptoms described above in Criteria B, C and D do NOT cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning
No symptoms
VA FORM 21-0960P-4, DEC 2010

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SECTION III - EVIDENCE REVIEW
NOTE: In order to provide an accurate medical opinion, the veteran's records should be reviewed (if available).
3A. WAS THE VETERAN'S VA CLAIMS FILE REVIEWED?
YES

NO

(If "No," complete Item 3B)

3B. CHECK ALL RECORDS THAT WERE REVIEWED AS PART OF THIS EXAMINATION:
Military service treatment records
Military service personnel records
Military enlistment examination
Military separation examination
Military post-deployment questionnaire
Department of Defense Form DD214, 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:

SECTION IV - STRESSORS
NOTE: For VA purposes, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance
that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised
explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon
friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror.
4. STRESSORS

A. STRESSOR # 1:
Describe the circumstance of stressor # 1
Are the veteran's symptoms related to this stressor?
YES

NO

(If "No," explain)

Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
YES

NO

Is this stressor related to the veteran's fear of hostile military or terrorist activity?
YES

NO

(If "No," explain)

B. STRESSOR # 2:
Describe the circumstance of stressor # 2
Are the veteran's symptoms related to this stressor?
YES

NO

(If "No," explain)

Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
YES

NO

Is this stressor related to the veteran's fear of hostile military or terrorist activity?
YES

NO

(If "No," explain)

C. STRESSOR # 3:
Describe the circumstance of stressor # 3
Are the veteran's symptoms related to this stressor?
YES

NO

(If "No," explain)

Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)?
YES

NO

Is this stressor related to the veteran's fear of hostile military or terrorist activity?
YES

NO

(If "No," explain)

D. ADDITIONAL STRESSORS (If additional stressors, describe):

VA FORM 21-0960P-4, DEC 2010

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SECTION V - SYMPTOMS
5. SYMPTOMS - FOR EACH LEVEL BELOW, CHECK ALL SYMPTOMS THAT APPLY. CONSIDER THE CUMULATIVE IMPACT OF ALL DIAGNOSED MENTAL
DISORDERS THAT THE EXAMINER JUDGES RELATED TO MILITARY SERVICE, WITHOUT ATTEMPTING TO DIFFERENTIATE WHICH SYMPTOMS ARE
SPECIFICALLY CAUSED BY WHICH MENTAL DISORDER
A. LEVEL I Has the veteran been diagnosed with PTSD (and/or other mental disorder), but symptoms are not severe enough either to interfere with occupational and social
functioning or to require continuous medications?
YES

NO

B. LEVEL II Does the veteran have 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 are the veteran's symptoms controlled by continuous medication?
YES

NO

C. LEVEL III Does the veteran have any symptoms from the list below?
YES

NO

(If "Yes," check all that apply)

Depressed mood
Anxiety
Suspiciousness
Panic attacks that occur weekly or less often
Chronic sleep impairment
Mild memory loss, such as forgetting names, directions or recent events
D. LEVEL IV Does the veteran have any symptoms from the list below?
YES

NO

(If "Yes," check all that apply)

Flattened affect
Circumstantial, circumlocutory or stereotyped speech
Panic attacks more than once a week
Difficulty in understanding complex commands
Impairment of short - and long - term memory, for example, retention of only highly learned material, while forgetting to complete tasks
Impaired judgment
Impaired abstract thinking
Disturbances of motivation and mood
Difficulty in establishing and maintaining effective work and social relationships
E. LEVEL V Does the veteran have any symptoms from the list below?
YES

NO

(If "Yes," check all that apply)

Suicidal ideation
Obsessional rituals which interfere with routine activities
Speech intermittently illogical, obscure, or irrelevant
Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively
Impaired impulse control, such as unprovoked irritability with periods of violence
Spatial disorientation
Neglect of personal appearance and hygiene
Difficulty in adapting to stressful circumstances, including work or a worklike setting
Inability to establish and maintain effective relationships
F. LEVEL VI Does the veteran have any symptoms from the list below?
YES

NO

(If "Yes," check all that apply)

Gross impairment in thought processes or communication
Persistent delusions or hallucinations
Grossly inappropriate behavior
Persistent danger of hurting self or others
Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene
Disorientation to time or place
Memory loss for names of close relatives, own occupation, or own name
VA FORM 21-0960P-4, DEC 2010

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SECTION V - SYMPTOMS (Continued)
5G. DOES THE VETERAN HAVE ANY OTHER SYMPTOMS ATTRIBUTABLE TO PTSD (and/or other mental disorder) THAT ARE NOT LISTED ON PAGE 4?
YES

NO

(If "Yes," describe):

SECTION VI - OCCUPATIONAL AND SOCIAL IMPAIRMENT
6. WHICH OF THE FOLLOWING BEST REPRESENTS THE VETERAN'S LEVEL OF OCCUPATIONAL AND SOCIAL IMPAIRMENT?
A mental condition has been formally diagnosed, but symptoms 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 symptoms 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 satisfactorily, 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

SECTION VII - GLOBAL ASSESSMENT OF FUNCTIONING (GAF)
7. PROVIDE THE CURRENT GLOBAL ASSESSMENT OF FUNCTIONING (GAF) SCORE

SECTION VIII - COMPETENCY
8. IS THE VETERAN CAPABLE OF MANAGING HIS OR HER FINANCIAL AFFAIRS?
YES

NO

(If "No," explain):
SECTION IX - DIAGNOSTIC TESTING

9. HAS ANY MENTAL HEALTH TESTING BEEN PERFORMED?
YES

NO

(If "Yes," provide dates, types of testing and results):

SECTION X - FUNCTIONAL IMPACT AND REMARKS
10. DOES THE VETERAN'S PTSD AND/OR OTHER MENTAL DISORDER(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact, providing one or more examples)

11. REMARKS (If any)

SECTION XI - PSYCHIATRIST/PSYCHOLOGIST CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
12A. PSYCHIATRIST/PSYCHOLOGIST SIGNATURE AND TITLE

12D. PSYCHIATRIST/PSYCHOLOGIST PHONE NUMBER

12B. PSYCHIATRIST/PSYCHOLOGIST PRINTED NAME

12C. DATE SIGNED

12E. PSYCHIATRIST/PSYCHOLOGIST LICENSE NUMBER 12F. PSYCHIATRIST/PSYCHOLOGIST ADDRESS

NOTE - VA may obtain additional medical information, including an examination, 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.
VA FORM 21-0960P-4, DEC 2010

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