Elysian Psychological Services

Veteran’s Disability Eligibility Assessment

This assessment will help begin your disability claim review. Elysian will review your submission and determine what further steps may be required to substantiate your claim.

Disability Eligibility Review

Personal Information

Please provide as much detail and be as clear as possible.
Name(Required)
MM slash DD slash YYYY
Address(Required)

Medical History

Symptoms and Impact on Daily Life

Incident(s) Leading to Condition

Previous and Current Treatments

Impact on Employment

Social and Family Impact

Assessments

In the last two weeks, how often have you been bothered by the following problems?
1. Feeling nervous, anxious, or on edge(Required)
2. Not being able to sleep or control worrying(Required)
3. Worrying too much about different things(Required)
4. Trouble relaxing(Required)
5. Being so restless that it is hard to sit still(Required)
6. Becoming easily annoyed or irritable(Required)
7. Feeling afraid, as if something awful might happen(Required)
In the last two weeks, how often have you been bothered by the following problems?
1. Little interest or pleasure in doing things?(Required)
2. Feeling down, depressed, or hopeless?(Required)
3. Trouble falling or staying asleep, or sleeping too much?(Required)
4. Feeling tired or having little energy?(Required)
5. Poor appetite or overeating?(Required)
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down?(Required)
7. Trouble concentrating on things, such as reading the newspaper or watching television?(Required)
8. Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?(Required)
9. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?(Required)
This questionnaire pertains to traumatic events you may have experienced in the past. Please read each question carefully and choose the answer that indicates how much you have been bothered by that problem in the last month.
1. Repeated, disturbing, and unwanted memories of the stressful experience?(Required)
2. Repeated, disturbing dreams of the stressful experience?(Required)
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?(Required)
4. Feeling very upset when something reminded you of the stressful experience?(Required)
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?(Required)
6. Avoiding memories, thoughts, or feelings related to the stressful experience?(Required)
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?(Required)
8. Trouble remembering important parts of the stressful experience?(Required)
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)?(Required)
10. Blaming yourself or someone else for the stressful experience or what happened after it?(Required)
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?(Required)
12. Loss of interest in activities that you used to enjoy?(Required)
13. Feeling distant or cut off from other people?(Required)
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?(Required)
15. Irritable behavior, angry outbursts, or acting aggressively?(Required)
16. Taking too many risks or doing things that could cause you harm?(Required)
17. Being “superalert” or watchful or on guard?(Required)
18. Feeling jumpy or easily startled?(Required)
19. Having difficulty concentrating?(Required)
20. Trouble falling or staying asleep?(Required)

Additional Information

Max. file size: 50 MB.
Consent(Required)

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