testpagedownload Full Name: Branch of Service: Years of service: What is your current status in the military? Type of discharge from military (if discharge has not yet occurred, please put N/A): Were you ever deployed to a combat zone? Please list all current service-connected disability/ies and their current percentage as well as effective date (please give the best estimate if you don’t know the exact date; or refer to your va.gov account, or most recent decision varter to get exact date) Are you seeking service connection for, or an increase for, your current Mental Health condition? Initial Service-connection Increase on my current disability rating Are you currently receiving Mental Health treatment Yes No Are you currently taking any medication? Yes No Do you already have a diagnosis of PTSD or any other mental health condition? Yes No Are you currently seeking a PTSD rating/diagnosis? Yes No 1. Please describe your social/marital/family history before/during/after your military service. 2. Please describe your occupational/educational history before/during/after your military service. 3. Please describe your mental health history to include prescribed medications as well as any history of mental health issues in your family before/during/after your military service. (if nothing please put N/A) 4. Please describe your legal and behavioral history before/during/after your military service. (if nothing please put N/A) 5. Please describe your substance abuse history before/during/after your military service. (if nothing please put N/A) 6. Please describe anything else you would like the psychologist to consider. (if nothing please put N/A) Over the last 2 weeks, how often have you been botheredby any of the following problems?(Use “✔” to indicate your answer 1. Little interest or pleasure in doing things Not at all Several Days Morethan halfthe days Nearly every Day 2. Feeling down, depressed, or hopeless Not at all Several Days Morethan halfthe days Nearly every Day 3. Trouble falling or staying asleep, or sleeping too much Not at all Several Days Morethan halfthe days Nearly every Day 4. Feeling tired or having little energy Not at all Several Days Morethan halfthe days Nearly every Day 5. Poor appetite or overeating Not at all Several Days Morethan halfthe days Nearly every Day 6. Feeling bad about yourself — or that you are a failure or have var yourself or your family down Not at all Several Days Morethan halfthe days Nearly every Day 7. Trouble concentrating on things, such as reading the newspaper or watching television Not at all Several Days Morethan halfthe days Nearly every Day 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual Not at all Several Days Morethan halfthe days Nearly every Day 9. Thoughts that you would be better off dead or of hurting yourself in some way Not at all Several Days Morethan halfthe days Nearly every Day If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not at all Several Days Morethan halfthe days Nearly every Day Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer 1. Little interest or pleasure in doing things Not at all Several Days Morethan halfthe days Nearly every Day 2. Not being able to stop or control worrying Not at all Several Days Morethan halfthe days Nearly every Day 3. Worrying too much about different things Not at all Several Days Morethan halfthe days Nearly every Day 4. Trouble relaxing Not at all Several Days Morethan halfthe days Nearly every Day 5. Being so restless that it’s hard to sit still Not at all Several Days Morethan halfthe days Nearly every Day 6. Becoming easily annoyed or irritable Not at all Several Days Morethan halfthe days Nearly every Day 7. Feeling afraid as if something awful might happen Not at all Several Days Morethan halfthe days Nearly every Day If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not at all Several Days Morethan halfthe days Nearly every Day 1. Repeated, disturbing, and unwanted memories of the stressful experience Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 2. Repeated, disturbing dreams of the stressful experience Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it) Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 4. Feeling very upset when something reminded you of the stressful experience Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating) Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 6. Avoiding memories, thoughts, or feelings related to the stressful experience Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations) Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 8. Trouble remembering important parts of the stressful experience Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is compvarely dangerous) Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 10. Blaming yourself or someone else for the stressful experience or what happened after it Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 10. Blaming yourself or someone else for the stressful experience or what happened after it Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 11. Having strong negative feelings such as fear, horror, anger, guilt, or shame Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 12. Loss of interest in activities that you used to enjoy Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 13. Feeling distant or cut off from other people Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you) Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 15. Irritable behavior, angry outbursts, or acting aggressively Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 16. Taking too many risks or doing things that could cause you harm Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 17. Being superalert or watchful or on guard Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 18. Feeling jumpy or easily startled Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 19. Having difficulty concentrating Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day 20. Trouble falling or staying asleep Not at all Several Days Morethan halfthe days Nearly every Day Nearly every Day Click to generate new document