VA Benefits Consultants
Mental Disorders Questionnaire
a) Please specify the condition(s) you are diagnosed with:
Please answer the following questions in paragraph form. A one sentence answer does not help with your rating and will delay the process. The more information we have the better. Include information about the situations in painting a picture of how it affected you during AND after your active duty military service.
Relevant Social/Marital/Family History
Please explain in detail how does your disability affect your social/marital and family condition NOW:
(Example: I am currently married and have a rocky relationship because my anxiety/PTSD makes it hard for me to socialize in everyday settings. I’d rather stay at home than go out to public areas where I feel like I have no control)
Relevant Occupational and Educational History
Please explain in detail how your disability affectS your occupation and educational condition NOW:
(Example: I have increased missed work due to stress and anxiety before going into work. I have a decrease in work quality/productivity because it is hard to focus on the different areas where there are deadlines. I have current tension with coworkers/supervisors and it has led me to be fired. I have gone from job to job in the past couple of years and currently I am not working.)
Please answer the following questions regarding your mental health history:
a) Are you currently undergoing counselling? If yes, indicate frequency.
b) Are you currently taking any medications? If yes, list all medication(s).
c) Do you think that your counselling/medications are improving your condition? Explain
Relevant Legal and Behavioral History
(Example: None reported OR DUI 6 months ago etc.)
Within the past year:
Relevant Substance Abuse History
Do you drink/smoke/drug use? If so, indicate frequency:
Do you feel competent to manage your financial affairs?
Yes | No |
Which of the following BEST describes your level of occupational and social impairment with regards to your mental disability?
No mental disorder diagnosis
Symptoms controlled by medication
Reduced reliability and productivity
Total occupational and social impairment
Symptoms are not severe enough to interfere with occupational and social functions
Occasional decrease in work efficiency
Deficiencies in most areas such as work, school, family relations, etc.
No mental disorder diagnosis | Symptoms are not severe enough to interfere with occupational and social functions | ||
Symptoms controlled by medication | Occasional decrease in work efficiency | ||
Reduced reliability and productivity | Deficiencies in most areas such as work, school, family relations, etc. | ||
Total occupational and social impairment |
Think of the symptoms you’ve had over the past year, not just what you have today and check all that apply:
Depressed Mood
Anxiety
Suspiciousness
Panic attacks (If yes, indicate frequency):
Near-continuous panic or depression affecting ability to function independently
Chronic Sleep impairment
Mild Memory loss (e.g. forgetting names, directions or recent events)
Impairment of short and long-term memory, retention of highly learned material, forgetting tasks etc.
Memory loss of names of close relatives, own occupation or own name
Flattened Affect (Decrease in your emotional expressiveness)
Speech disorder
Difficulty in understanding complex commands
Impaired Judgment
Impaired abstract thinking
Impairment in thought process or communication
Disturbances of mood and motivation
Difficulty in establishing and maintaining effective work and social relationships
Difficulty adapting to stressful circumstances, including weak and social relationships
Suicidal Ideas
Obsessional rituals which interfere with normal routine
Impaired impulse control, such as unprovoked irritability with periods of violence
Spatial disorientation (Inability to determine your own position, location and motion)
Persistent delusions or hallucinations (apparent perception of something not present)
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
Depressed Mood | Anxiety | ||
Suspiciousness | Panic attacks (If yes, indicate frequency): | ||
Near-continuous panic or depression affecting ability to function independently | Chronic Sleep impairment | ||
Mild Memory loss (e.g. forgetting names, directions or recent events) | Impairment of short and long-term memory, retention of highly learned material, forgetting tasks etc. | ||
Memory loss of names of close relatives, own occupation or own name | Flattened Affect (Decrease in your emotional expressiveness) | ||
Speech disorder | Difficulty in understanding complex commands | ||
Impaired Judgment | Impaired abstract thinking | ||
Impairment in thought process or communication | Disturbances of mood and motivation | ||
Difficulty in establishing and maintaining effective work and social relationships | Difficulty adapting to stressful circumstances, including weak and social relationships | ||
Suicidal Ideas | Obsessional rituals which interfere with normal routine | ||
Impaired impulse control, such as unprovoked irritability with periods of violence | Spatial disorientation (Inability to determine your own position, location and motion) | ||
Persistent delusions or hallucinations (apparent perception of something not present) | 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 |
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