PTSD Worksheet

Your History of Combat ServiceWe 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. Also, you must help your examining psychiatrist or psychologist understand the nature of your military service and how it relates to your condition.

The following worksheet is designed to assist you in providing your veterans service representative and examining physician with the information he or she will need. Remember:

There is no substitute for doing a PTSD claim properly the first time.
Doing an incomplete job, at best will delay your claim; at worst being less than thorough can compromise your initial 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 will 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 HISTORYBranch of Service: _____________________________ Highest Rank and Pay Grade: ____________________Rank and Pay Grade at Discharge: ________________Date Entered Service: __________________________Date of Discharge: _____________________________

Character of Discharge: _________________________

YOUR COMBAT ASSIGNMENTRank 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 DUTIESWhile 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 FrequentlyIf 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 NoIf 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 FrequentlyOther, 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 NoSince 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 AWARDSWere you injured or wounded during your combat service? (circle answer) Yes NoIf 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 WORDSIn 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.

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