Your
History of Combat Service
We cannot overstate the need to get competent
help in filing a VA claim for compensation based on Post-Traumatic Stress Disorder (PTSD).
Notwithstanding that advice, it is your claim and it is your responsibility to provide your representative with the
information needed to successfully prepare, present and prosecute your claim.
The following worksheet is designed to
assist you in providing your veterans service representative with the information he or she will need. There is no substitute
for doing a PTSD claim properly the first time. Doing an incomplete job can compromise
your claim, your appeal if necessary, and any subsequent claim.
This worksheet is focused on addressing
the evidentiary requirements of a VA claim for compensation based on PTSD. Done properly and honestly, the worksheet
will help you define the trauma so that your stressor can be documented. It can also help a psychiatrist understand
your trauma and assess its impact on your life.
If you are a recently returned combat
veteran, even if you believe you do not suffer from PTSD, complete this worksheet while the information is fresh in your
mind. Then, put the worksheet in a secure place. Years from now, should you develop symptoms, the information
on the completed worksheet can be invaluable.
Doing this worksheet properly may
dredge up some difficult memories and images. Don’t let this tempt you into rushing through the worksheet or into
completing it haphazardly. If something bothers you, set the worksheet aside and come back to it later.
Print this worksheet and use it as
your guide to developing a detailed personal history of your combat service. This worksheet and the following pamphlet
on getting a fair VA disability evaluation will give you a wealth of information to help you assemble a successful claim.
PTSD
WORKSHEET
A
Veterans Service Publication of PTSDhelp.net
Your Full Name: _________________________________
Social Security No.: _____________________________
Military Service No.: _____________________________
YOUR MILITARY HISTORY
Branch of Service: _____________________________
Highest Rank and Pay Grade: ____________________
Rank and Pay Grade at Discharge: ________________
Date Entered Service: __________________________
Date of Discharge: _____________________________
Character of Discharge: _________________________
YOUR COMBAT ASSIGNMENT
Rank During Combat: _____________________________
Your Primary MOS: _______________________________
Your Duty MOS (if different): _________________________
Combat Theater(s): ______________________________
Combat Unit: ___________________________________
Dates of Assignment to This Unit:
From ____________________ To ___________________
Combat duty assignment:
_______________________________________________
Describe your duties:
_______________________________________________
_______________________________________________
YOUR COMBAT DUTIES
While in your combat assignment were you mainly (circle answer):
On a base?
In the field?
If both, explain:
_______________________________________________
_______________________________________________
_______________________________________________
While in your combat assignment how often did you do the following?
(circle answers.)
Fire a weapon at the enemy:
Never Rarely
Often Frequently
Kill or likely kill your target:
Never Rarely
Often Frequently
See someone killed or dying:
Never Rarely
Often Frequently
See dead bodies, civilian, or enemy:
Never Rarely
Often Frequently
See American dead:
Never Rarely
Often Frequently
If you were present when Americans were killed can you list several
of their names and the approximate date of their deaths?
Name: _______________________________________________
Date KIA: __________
Name: _______________________________________________
Date KIA: __________
Name: _______________________________________________
Date KIA: __________
If you listed the names of American casualties in the preceding question,
were any of them close friends? (circle answer)
No Yes
If yes, who? ____________________________________
Did you handle any bodies? (circle answer.)
Yes No
If yes, describe your inner feelings at the time.
_______________________________________________
_______________________________________________
_______________________________________________
Did you participate in firefights? (circle answer.)
No Yes
How many? _____________________________________
Describe in general terms your responsibilities in a firefight.
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Did you or your unit experience any of the following? (circle a frequency for all that apply)
Sniper Fire:
Never
Rarely Often Frequently
Rocket/Mortar attacks:
Never
Rarely Often Frequently
Mines/Booby Traps (anti-Personnel):
Never Rarely Often Frequently
Mines/Booby Traps (anti-Vehicular):
Never Rarely
Often Frequently
Ambush:
Never Rarely
Often Frequently
Other, explain:
_______________________________________________
_______________________________________________
Describe any combat experience that stands out as especially threatening
to you. Explain how you survived that situation.
_______________________________________________
_______________________________________________
_______________________________________________
During your assignment to combat duties did you feel that the experience was stressful? If so, please briefly explain.
_______________________________________________
_______________________________________________
_______________________________________________
Did you use alcohol or drugs to cope with
the stress of your combat experience? (circle answer)
Yes No
Since your
return from combat do you have (briefly
explain all that apply):
Frequent or intrusive memories of combat?
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Dreams?
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Nightmares?
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Flashbacks?
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
For each,
how often? (circle answers)
Memories:
Never Rarely
Often Daily
Dreams:
Never Rarely
Often Daily
Nightmares:
Never Rarely Often Daily
Flashbacks:
Never Rarely
Often Daily
DECORATIONS AND AWARDS
Were you injured or wounded during your combat service? (circle answer)
Yes
No
If yes, describe the nature and severity of your injury or wound.
_______________________________________________
_______________________________________________
List your combat-related decorations and awards.
_______________________________________________
_______________________________________________
HOW DO YOU FEEL NOW?
Do you ever seem to shut out the world? If yes, explain:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Do you ever feel as if your emotions were drained out of you?
If yes, explain:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Do you avoid
things that remind you of combat, or do you enjoy the things that remind you of your war experiences? Explain your answer in detail:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Do you find that your post-combat life is somehow boring and less meaningful
than your life was before? If so, explain:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Do things that should be important to you in your life after combat
service somehow seem less important than before? If so, explain and give an example:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Do you find it hard to control your anger? Specifically, do things
that shouldn’t bother you cause you to be angry? Explain:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Do you think of suicide or of hurting other people, or both?
Explain:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Are their specific dates from your combat service that are particularly
significant in your mind? If so, list some and explain there significance:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Do these anniversary dates bother you? If so, explain:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Has your interest in activities changed since you began experiencing
problems related to your combat service? If so, detail some of those activity changes:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Do you feel estranged from others? If so, explain how and whom:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
What are your plans for the future?
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Are you comfortable in large
crowds, or do you prefer to be alone? Explain:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Do loud noises bother you? Are you jumpy
or nervous? Do you have an exaggerated startle response? Explain:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
IN
YOUR OWN WORDS
In your
own words describe the most traumatic event of your combat service. Write separately on as much paper as you
need. In addition to names and dates, give specific details of the event. For example:
- What you experienced.
- How you felt at the time.
- What you saw, heard, and smelled.
- Where you were.
- What you did during the event.
- What you felt like immediately after the event.
- What
you feel like about it now.
Doing this
worksheet can be difficult. If it stresses you out — take a break. Some
vets find it helpful to get a friend to write for them as they talk.
What you’re
doing here is trying to pin down in the greatest possible detail the most traumatic stressor of your combat service. It’s helpful for current or future treatment or a VA compensation claim
to commit to paper as much detail as you can recall. Try to use simple “civilian” language. The over-use
of military terminology can be confusing to those without military backgrounds.