INITIAL EVALUATION FOR POST-TRAUMATIC STRESS DISORDER (PTSD)

# 0910 Worksheet

Name:                                    

SSN:      

Date of Exam:                              

C-number:        

Place of Exam:                                    

 

The following health care providers can perform initial examinations for PTSD.

a board-certified or board “eligible” psychiatrist;

a licensed doctorate-level psychologist;

a doctorate-level mental health provider under the close supervision of a board-certified or board eligible psychiatrist or licensed doctorate-level psychologist

a psychiatry resident under close supervision of a board certified or board eligible psychiatrist or licensed doctorate-level psychologist; 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.

A. Identifying Information:

  • age

  • ethnic background

  • era of military service

  • reason for referral (original exam to establish PTSD diagnosis and related psychosocial impairment; re-evaluation of status of existing service-connected PTSD condition)

B. Sources of Information:

  • records reviewed (C-file, DD-214, medical records, other documentation)

  • review of social-industrial survey completed by social worker

  • statements from collaterals

  • administration of psychometric tests and questionnaires (identify here)

C. Review of Medical Records:

  1. Past Medical History:



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement