PTSD DEVELOPMENT SHEET
Name____________________________ date______________ SSN______________________
Branch of service_______________ service #________________________ Highest rank ____________
Rank during combat_____________ Rank at discharge_________________ VA claim # ____________
MOS__________ Combat duty assignment ___________________ Describe duty ___________________
During combat were you mainly on: Base ____ Field ____ Ship ____ describe_________________________
While in a combat situation area, how often did you: (choose the word that best fits: never, rarely, often)
fire your weapon at the enemy _____ kill the enemy ______ see someone killed ________ observe death_____, was it our side or their side? _______.
Were any of your comrades killed? ____ Who ___________________________________________ rank ____
Were you in firefights? _____ What did you do? ________________________________________
Did you handle body bags? _______ Describe your inner feelings ___________________________
______________________________________________________________________________________
Did you or your unit receive sniper, mortar or rocket attacks? _____ What and how many? ___________________
Describe how you survived ______________________________________________________________________
Before proceeding further, please describe a situation(s) you thought you would not survive (stressor). Do this on a separate sheet and submit with this form. This is extremely important and a major factor in a PTSD claim. It is required.
Considering the incident circle that which applies most
somewhat stressful moderately stressful extremely stressful
Did you use drugs or alcohol during your stressor event? _____ if so which? ________
Since your stressor how often do you have: nightmares ____ flashbacks ____ prolonged memories ___
Were you injured or wounded? Yes____ No _____ describe ____________________________________
List your combat medals or ribbons ________________________________________________________
Do you seem to shut out the world? Yes____ No _____
How have your emotions changed?____ describe ______________________________________________
Do you avoid some things you enjoyed before your stressor? _____________________________________
List the date of the traumatic experience_____________
Do anniversaries of the incident bother you? Yes____ No _____ If yes explain _______________________
How has your interest in activities changed since the trauma? ___________________________________
____________________________________________________________________________________
Are you estranged from others? Yes____ No _____ Explain _____________________________________
Do you have loving feelings?____ Toward who?_______________________________________________
Have your arousal symptoms changed (example: anger, mellow out)? Yes____ No _____ Explain
____________________________________________________________________________________
Do you have irritability or outbursts of anger? Yes____ No _____ Explain _________________________
Are you on constant alert? ____ Do you feel someone is about to jump you? _____ Why? ______________
Are you jumpy? _____ Exaggerated startle response, tense, goosey? ______
What are your plans for the future?
_________________________________________________________
When a person files for Post Traumatic Stress Disorder, the Rating Board, of the Department of Veterans Affairs requires several mandatory conditions. We cannot assist any veteran in completion of a successful claim without these conditions being met. We must have a diagnosis competent medical authority, a psychiatrist; record of proof of a stressor. You must be in treatment for the condition and you must meet the criteria stated in DSM IV. You must furnish a written stressor in detail. You need to give approximate dates and names of those killed if involved in your stressor. We will assist you in research for the pertinent data.
Please understand this is a long claim process. You must notify this office upon receipt of letters or phone calls from the VA. You must keep all mental health appointments.
Every veteran filing a claim through this office is expected to give accurate information. We need facts with no exaggeration. Intentional deceit voids this claim. The veteran will not be mislead and the Veterans Service Officer expects the same in return. In signing this form you agree to the above conditions.
Signature of the veteran__________________________________ date _______________
VSC March 1, 1984
REVISIONS: April 17, 1986, October 25, 2001
Click Here To Go Back