Patient's Name *

First Name Last Name

Date *

Social Security Number *

Date of Birth *

Race *

Age *

Gender *

Drivers License/Military ID Number *

Please upload a copy of your drivers license or military ID

Browse Files

Please complete the following information:

Military History

Branch *

Entry Date *

Discharge Date *

Combat Tours *

Yes No

Highest Rank *

Discharge Rank *

Job/MOS/Duties *

0/5000

Any Disciplinary Actions in Service? *

Yes No

Any Legal Action Occur in Service? *

Yes No

Date of your last C&P exam?

This can be an approximate date

Since your previous exam, have you had any changes in the following:

Any significant difficulties with social or marital issues? *

Yes No

Any diagnosis of a mental health condition since your last exam? *

Yes No

Are you aware of any family history of mental health diagnosis? *

Yes No

Any Mental Health Treatment since your last exam? (This includes continuation of previously reported treatment) *

Yes No

Have you been hospitalized for a mental health condition? (such as severe anxiety, PTSD, depression, substance dependence, bipolar, etc.) *

Yes No

Please list every mental facility that you have been treated at ad the dates if possible: *

0/5000

Have you engaged in any education? (Degrees, certificates, training) *

Yes No

Have you worked since your last C&P exam? *

Yes No

What kind of jobs have you had? When did you last work? *

0/5000

Any legal history (arrest, charges, jail time) since your last C&P evaluation? *

Yes No

If so, please explain:

0/5000

SUBSTANCE USE

Any history of substance use since your last C&P exam? If so, please indicate which substances you have used or are currently using. *Please note this does not include medication prescribed to you by a doctor. *

If other, please specify below:

0/1000

Have you suffered consequences because of your substance use? *

Yes No

Have you ever experienced withdrawal? *

Yes No

Have you ever been treated for substance use, abuse or dependence? *

Yes No

Below are difficulties that are sometimes reported:

PHQ-9 Depression

Over the last 2 weeks, how often have you been bothered by any of the following problems? *

Not at all

Several Days

More than half the days

Nearly every day

1) Little interest or pleasure in doing things...

2) Feeling down, depressed, or hopeless...

3) Trouble falling or staying asleep, or sleeping too much...

4) Feeling tired or having little energy...

5) Poor appetite or overeating...

6) Feeling bad about yourself - or that you are a failure or have let yourself or your family down...

7) Trouble Concentrating on things, such as reading the newspaper or watching television...

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...

9) Thoughts that you would be better off dead or of hurting yourself in some way...

Not at All Total

Several Days Total

More than half the days Total

Nearly every day Total

Total Score

From the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ). The PHQ was developed by Drs. Robert L. Spitzer. Janet B.W. Williams, Kurt Kroenke, and colleagues. For research information, contact Dr. Spitzer at ris8@columbia.edu. PRIME-MD@ is a trademark of Pfizer Inc. Copyright@ 1999 Pfizer Inc. All rights reserved. Reproduced with permission

GAD-7 Anxiety

Over the last 2 weeks, how often have you been bothered by the following problems? *

Not at All

Several Days

More than half the Days

Nearly Every Day

1) Feeling nervous, anxious or on edge?

2) Not being able to stop or control worrying

3) Worrying too much about different things

4) Trouble relaxing

5) Being so restless that it is hard to sit still

6) Becoming easily annoyed or irritable

7) Feeling afraid as if something awful might happen

Not at All Total

Several Days Total

More than half the Days Total

Nearly Every Day Total

Total Score

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 Difficult Somewhat Difficult Very Difficult Extremely Difficult

From the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ), The PHQ was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues. For research information, contact Dr. Spitzer at rls8@columbia.edu. PRIME-MDØ is a trademark of Pfizer Inc. Copyright© 1999 Inc. All rights reserved. Reproduced with permission

Adverse Childhood Experience (ACE) Questionnaire

Finding your ACE Score

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often...

Swear at your, insult you, put you down, or humiliate you?

OR

Act in a way that made you afraid that you might be physically hurt?

Yes or No

If Yes enter 1, if No enter a 0 *

2. Did a parent or other adult in the household often...

Push, grab, slap, or throw something at you?

OR

Ever hit you so hard that you had marks or were injured?

Yes or No

If Yes enter 1, if No enter a 0 *

3. Did an adult or person at least 5 years older than you ever...

Touch or fondle you or have you touch their body in a sexual way?

OR

Try to or actually7 have oral, anal, or vaginal sex with you?

Yes or No

If Yes enter 1, if No enter a 0 *

4. Did you often feel that...

No one in your family loved you or thought you were important or special?

OR

Your family didn't look out for each other, feel close to each other, or support each other?

Yes or No

If Yes enter 1, if No enter a 0 *

5. Did you often feel that...

You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you?

OR

Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

Yes or No

If Yes enter 1, if No enter a 0 *

6. Were your parents ever separated or divorced?

Yes or No

If Yes enter 1, if No enter a 0 *

7. Was your mother or stepmother:

Often pushed, grabbed slapped, or had something thrown at her?

OR

Sometimes or often kicked, bitten hit with a fist, or hit with something hard?

OR

Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

Yes or No

If Yes enter 1, if No enter a 0 *

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

Yes or No

If Yes enter 1, if No enter a 0 *

9. Was a household member depressed or mentally ill or did a household member attempt suicide?

Yes or No

If Yes enter 1, if No enter a 0 *

10. Did a household member go to prison?

Yes or No

If Yes enter 1, if No enter a 0 *

Total Score (This is your ACE Score)

PCL-5

Instructions: This questionnaire asks about problems you may have had after a very stressful experience involving actual or threatened death, serious injury or sexual violence. It could be something that happened to you directly, something you witnessed, or something you learned happened to a close family member or close friend. Some examples are a serious accident, fire, disasters such as a hurricane, tornado, or earthquake, physical or sexual attack or abuse, war, homicide, or suicide.

First, please answer a few questions about your worst event, which for this questionnaire means the event that currently bothers you the most. This could be one of the examples above or some other very stressful experience. Also, it could be a single event (for example, a car crash) or multiple similar events (for example, multiple stressful events in a warzone or repeated sexual abuse).

Briefly describe the worst event (if you feel comfortable) *

0/2000

How long ago did it happen? (Please estimate if you are not sure) *

Did it involve actual or threatened death, serious injury, or sexual violence? *

Yes No

How did you experience it? *

It happened to me directly I witnessed it I learned about it happening to a close family member or close friend I was repeatedlyexposed to details about it as part of my job (for example, paramedic, police, military, or other first responder) Other (Please describe below)

0/2000

If the event involved the death of a close family member or close friend, was it due to some kind of accident or violence, or was it due to natural causes? *

Accident or violence Natural Causes Not applicable (the event did not involve the death of a close family member or close friend)

Instructions: Below are a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then check the box in the coordinating column to indicate how much you have been bothered by that problem in the past month.

In the past month, how much were you bothered by: *

Not at All

A Little Bit

Moderately

Quite a Bit

Extremely

1. Repeated, disturbing, and unwanted memories of the stressful experience?

2. Repeated, disturbing dreams of the stressful experience?

3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it.)

4. Feeling very upset when something reminded you of the stressful experience?

5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?

6. Avoiding memories, thoughts, or feelings related to the stressful experience?

7. Avoiding external reminders of the stressful experience (for example people, places, conversations, activities, objects, or situations)?

8. Trouble remembering important parts of the stressful experience?

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 completely dangerous)?

10. Blaming yourself or someone else for the stressful experience or what happened after it?

11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?

12. Loss of interest in activities that you used to enjoy?

13. Feeling distant or cut off from other people?

14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

15. Irritable behavior, angry outbursts, or acting aggressively?

16. Taking too many risks or doing things that could cause you harm?

17. Being "superalert" or watchful or on guard?

18. Feeling jumpy or easily startled?

19. Having difficulty concentrating?

20. Trouble falling or staying asleep?

AUDIT-C Questionnarie

1. How often do you have a drink containing alcohol? *

a. Never b. Monthly or Less c. 2-4 times a month d. 2-3 times a week e. 4 or more times a week

How many standard drinks containing alcohol do you have on a typical day? *

a. 1 or 2 b. 3 or 4 c. 5 or 6 d. 7 to 9 e. 10 or more

How often do you have six or more drinks on one occasion? *

a. Never b. Less than monthly c. Monthly d. Weekly e. Daily or almost daily

I understand that a typed version of my name may be accepted as my original signature pursuant to the Georgia Uniform Electronic Transactions Act (O.C.G.A. 10-12-7). To accept the above statement, type "I Understand" in the box below. *

Patient Signature (Please Type the Patients Full Name) *

Date *

Patient's Signature *

In order for the submission to be accepted, you must use your mouse to draw your signature in the box above. Clear

Veterans Evaluation Services Form