PTSD Development
Name____________________________ date______________
SSN______________________________
Branch of service_______________ Highest rank_____________ Rank at discharge________________________
VA Claim#_______________________ MOS__________ Describe your duties_________________
Describe the stressor incident___________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________________________
use separate sheet if more space is needed.
Describe how you coped with the incident
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Considering the incident circle that which applies most
()somewhat stressful ()moderately stressful ()extremely stressful
Did you use drugs or alcohol before or after the traumatic event?
Were you injured or wounded? Yes____ No _____
Do you seem to shut out the world? Yes____ No _____
How have your emotions changed
_______________________________________________________________
Do you avoid some things you enjoyed before your stressor?
___________________________________________
List the date of the trauma incident_____________
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
___________________________________________________________________________________________
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? Yes____ No _____
When a person files for PTSD there are several mandatory conditions required by the VA. These conditions must be met in order to successfully prosecute a claim. We need a diagnosis from competent medical authority, proof of the stressor and treatment of the condition showing it currently exists. This must comply with DSM IV.
A written stressor in detail must be submitted. Please understand this is a long claim process. All mental health appointments must be adhered to. Intentional deceit voids this claim. The veteran will not be mislead and the Veterans Service Officer expects the same in return.
Signature of the veteran__________________________________ date _______________
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