MENTAL DISABILITY MINI-DBQ (Disability Benefits Questionnaire)

MENTAL MINI-DBQ

(PTSD, Depression, Anxiety, etc.)

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! This information is used to provide the VA with symptoms associated with your mental condition as they are currently seen. Vague information does not help! 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

Current Symptoms of how it affects you 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

Current Symptoms of how it affects you NOW:

(Example: I have increased missed work due to stress and anxiety before going into work. I have 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.) DocuSign Envelope ID: DC2FDA7D-A0C5-4809-AC53-3F7546B25EEE WELL I STILL GET DISTURBING THOUGHTS. AND HAVE BAD DREAMS ABOUT THE HOLE EVENTS ..i live alone and i don't socialize much and i stay away from big crowds. its lonely at time..dont have much friends.. i tend to deal with it day by day.. i lost two jobs and can't seem to react with other.. so i drive alone not with a parter. IAM A TRUCK DRIVER...SO FAR IM DOING GOOD ON THIS PRESENT JOB.. MENTAL DISABILITY MINI-DBQ (Disability Benefits Questionnaire) RELEVANT MENTAL HEALTH HISTORY, TO INCLUDE PRESCRIBED MEDICATIONS AND FAMILY MENTAL HEALTH

Current counseling / medications and how it affects you NOW:

(Example: Currently attending counseling and therapy with VA every 6 months. I feel that I have little improvement. I am currently on prescription for the past __ years/ months) RELEVANT LEGAL AND BEHAVIORAL HISTORY

Within the past year:

example: None reported OR DUI 6 months ago

RELEVANT SUBSTANCE ABUSE HISTORY

Current Substance abuse of how it affects you NOW: example: Denied, none reported, I drink 3 cases of beer every night 6. DO YOU FEEL COMPETENT TO MANAGE YOUR FINANCIAL AFFAIRS? Yes No (you will NOT be able to buy or carry a weapon and a fiduciary will be assigned to handle your money.)

DocuSign Envelope ID: DC2FDA7D-A0C5-4809-AC53-3F7546B25EEE X

NONE LEGAL BEHAVIORAL HAVE BEEN REPORTED.. I DONT BELIVE GETTING INTO COMPENSATION WITH THE LAW..

I ONLY TOUCH ALCOHOL ON WEEKENDS...

I REFUSE TO SEE COUNSELING OR THERAPY..I SEE MY VA DR.ONCE A YEAR TO MAKE SURE ALLMY BLOOD WORKS COMES BACK GOOD..I ONLY RECEIVE MEDICATIONS FOR OTHER THINGS LIKE MY LOWER BACK PAIN..

MENTAL DISABILITY MINI-DBQ (Disability Benefits Questionnaire) Think about your level of impairment towards occupational and social the farther down on the scale you are the greater the disability. Please be honest.

Which of the following BEST describes your level of occupational and social impairment with regard to your mental disability?

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. The symptoms checked off below will determine your percentage disability and how it affects your occupational and social impairment.

Depressed mood (30% Criteria)

Anxiety (30% Criteria)

Suspiciousness (30% Criteria)

Panic attacks that occur weekly or less often (30% Criteria)

Panic attacks more than once a week (50%

Criteria)

Near-continuous panic or depression affecting

ability to function independently (70% criteria)

Chronic sleep impairment (30% Criteria)

Mild memory loss, such as forgetting names,

directions or recent events (30% Criteria)

Impairment of short and long-term memory,

retention of highly learned material, forgetting tasks

(50% Criteria)

Memory loss of names of close relatives, own

occupation, or own name (100% criteria)

Flattened affect (50% Criteria)

Circumstantial, circumlocutory or stereotyped

speech (50% Criteria)

Speech intermittently illogical, obscure, or

irrelevant (70% criteria)

Difficulty in understanding complex commands

(50% Criteria)

Impaired judgement (50% Criteria)

Impaired abstract thinking (50% Criteria)

Gross impairment in thought process or

communications (100% criteria)

Disturbances of motivation and mood (50%

Criteria)

Difficulty establishing and maintaining effective

work and social relations (50% Criteria)

Difficulty adapting to stressful circumstances,

including work or work like settings (70% criteria) Inability to establish and maintain effective

relationships (70% criteria)

Suicidal ideations (70% criteria)

Obsessional rituals which interfere with routine

activities (70% SC criteria)

Impaired impulse control, such as unprovoked

irritability with periods of violence (70% criteria) Spatial disorientation (70% criteria)

Persistent delusions or hallucinations

(100% criteria)

Grossly inappropriate behavior (100% criteria)

Persistent danger of hurting self or others

(100% criteria)

Neglect of personal appearance and hygiene (70%

criteria)

Intermittent inability to perform activities of daily living, including maintenance of minimal personal

hygiene (100% criteria)

Disorientation to time or place (100% criteria)

CERTIFICATION – To the best of my knowledge, the information contained herein is accurate, complete, and current. I understand that OVERSTATING the severity of my conditions on official Disability Benefit Questionnaires (DBQs) could result in loss of benefits and/or be considered fraudulent. I am conveying the severity of my symptoms to the best of my ability on this personal assessment form. No one has advised me to misrepresent my conditions or overstate the severity of my symptoms.

PRINTED NAME: SIGNATURE:

DATE EMAIL ADDRESS

DocuSign Envelope ID: DC2FDA7D-A0C5-4809-AC53-3F7546B25EEE X

ARTHUR FLORES

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9/29/2019

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adbhij@r.postjobfree.com

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