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I have had a great many people ask and have used this Self-Report for Social Security Disability Income and the VA. With the VA, simply remove the law about PTSD and the disorder numbers in the List of Impairments and then this report can be used to file for VA compensation. This report is a composite of many issues suffered by different veterans complied into a sample report. This report in no way guarantees successful achievement of SSDI or VA Compensation. Nor should this report be copied and used word-for-word. It is merely a tool to help those seeking SSDI and VA Compensation frame their own self-reports.
Social Security Claims (or VA Compensation)
Medical and Mental Disorders
John Doe Smith DOB: 04/04/47
122 Main Street SSN: 123-45-6789
BACKGROUND: I was employed at ABC Industries and currently rated 90% service-connected by the Veterans Administration for Post-traumatic Stress Disorder and Major Depression with secondary conditions of Generalized Anxiety Disorder and Panic Disorder with Agoraphobia, Diabetes type II (Agent Orange induced) with secondary problems with Peripheral Neuropathy, Bilateral Cataracts, Peripapillary Atrophy. Chloracne, Acne Conglobata with residuals (Agent Orange induced), Sensorineural hearing loss, Tinnitus, Rotator Cuff Damage, and Hypertension. I have an application currently in process (or I am 100% permanent and total) by the Veterans Administration.
(FOR SOCIAL SECURITY PURPOSES ONLY IN BOLD PRINT)`
I understand that the Social Security Administration uses DSM-IV to determine if an applicant has a particular mental disability.
I have been diagnosed by the Veterans Administration with Post Traumatic Stress Disorder (PTSD). While I understand the SSA is not required to accept the diagnosis of the VA I wish to bring the following to your attention:
Under CFR 20, Appendix 1 to Subpart P, paragraph 12.06 (List of Impairments) Anxiety Related Disorders (the DSM-IV has PTSD listed under a "Stress Response" category, which comes under their "anxiety disorder" category) the List of Impairments says:
"A. Medically documented findings of at least one of the following, referring to items 1 through 5 under "A"
Your # 1(d) corresponds directly with item d (4) in section 309.81, "Anxiety Disorders", of DSM-IV.
Your # 2 corresponds directly with item c (2) in section 309.81, "Anxiety Disorders", of DSM-IV.
Your # 5 corresponds directly with item b (1) in section 309.81, "Anxiety Disorders", of DSM-IV.
As you can see PTSD fulfills THREE of the requirements, not just ONE.
B. Resulting in at lease two of the following:
Your # 2 corresponds directly with item c (2) in section 309.81, "Anxiety Disorders", of DSM-IV.
Your # 3 corresponds directly with item d (3) in section 309.81, "Anxiety Disorders", of DSM-IV.
Your # 4 corresponds directly with item d (2) & d (3) in section 309.81, "Anxiety Disorders", of DSM-IV.
PTSD fulfills THREE requirements, not just two.
Your attention is invited to 20 CFR 303.1520 (d) which states, "If you have an impairment(s)which meets the duration requirement and is listed in appendix 1 OR is equal to a listed impairment(s), we will find you disabled without considering your age, education, and work experience."
The introduction to the List of Impairments says "The listings are so constructed that an individual with an impairment(s) that meets or is equivalent in severity to the criteria of a listing could not reasonably be expected to do any gainful activity" therefore a residual functional capacity (RFC) evaluation should not be required.
If you do not agree with the "List of Impairments" data presented above please provide the reason for disagreement."
The above format for SSDI can be used for any mental disorder by locating Chapter 12.00 of the SSA Blue Book and applying the requirements for a specific disorder).
Example of a Self-Report:
My Medical and Mental Disorders cause the following problems:
Post-traumatic Stress Disorder (From SSDI Blue Book: Anxiety Disorders 12.06): I served with the US Marine Corps in Vietnam and was wounded suffering shell fragmentation wounds over 70% of my body. On one occasion I was one of 35 survivors of a combat unit consisting of 250 Marines. I witnessed significant deaths and wounds as a result. Fighting was often fierce, ferocious, and intense. I witnessed many deaths and casualties on both sides. These casualties occurred because of fierce fire fights, mortar, mines, artillery and rocket rounds, booby-traps, ambushes, acts of terrorism ("snipers and sappers"), and hand-to-hand combat. I experienced all the above mentioned actions.
Occupational Limitations: For 30 years I have continuous nightmares and night terrors, startled responses, hypervigilance, flashbacks, reliving experiences, intrusive thoughts, sleep disturbance, mood disturbances (anger and irritability, daily panic disorder, anxiety, fatigue, and depression), restriction of affect, poor social interactions, immediate and short term memory problems, and reactivity to events that include images and recollections of my time in Vietnam.
I also experience marked avoidant behaviors and find isolation more preferable to interactions with others. I tend to avoid crowds, people and situations that do not provide me an opportunity to escape. I have a sense of detachment from others and do not seek to interact with anyone. I have come to realize that I can no longer work in my profession because of these issues and my preoccupation with intrusive thoughts concerning my experiences in Vietnam. Intrusive thoughts have been present since I left Vietnam and have grown in intensity. I constantly ruminate about events and my experiences in Vietnam. These experiences have progressively become worse over the past year inhibiting my ability to perform my professional functions and responsibilities.
In my recent rating from the Veterans Administration, the examiner states "the examiner assess that your ability to work given your current situation in your occupation is considered significantly impaired. The Global Adaptive
Functioning is 35 (assigned for some impairment in reality testing or communication or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood)."
More often than not, I mix things up and have to continually correct these errors. Recently, I have gotten angry with people causing them stress and negative feelings as a result. It is difficult to perform my professional responsibilities out of fear that I may make a critical mistake causing harm to another individual. I have found that participating in my professional employment exacerbates my stress, mental disorders generating panic attacks, stress, and depressive episodes.
TREATMENT: My treatment began as early as 1974 by a Dr. (Name), Psychiatrist for the Vine Street Clinic in Illinois for problems related to Combat Stress and was given a prescription of Tofranil. The clinic and psychiatrist have both ceased to exist. Later, I received treatment through VA facilities in both St. Louis, Missouri, Chicago, Illinois, private providers., and Asheville, North Carolina.
Currently, I attend outpatient mental health treatment at the VA Medical Center in Asheville, North Carolina, I am prescribed Paxil 30 mgs once daily by the VA Medical Center in Asheville, North Carolina. Paxil is an FDA approved drug for treatment of PTSD, Panic Disorder, Depression, and Social Phobia. Along with Paxil I am also prescribed Depakote 1000 mgs per day
Major Depression (Affective Disorders 12.04): I have a history of depression secondary to Post-traumatic Stress Disorder.
Occupational Limitations: I suffer from Major Depression comorbid with Post-traumatic Stress Disorder and Anxiety Disorders. I have loss of interest in activities, psychomotor agitation, lack of energy, feelings of guilt, sadness more days than not, suicidal ideation, and sleep disturbance. It causes difficulty in concentration and persistence, difficulty maintaining social functioning, and diminished restriction of daily activities. These symptoms have been diagnosed by several physicians in the past, and currently by the Veterans Administration.
Treatment: I currently receive treatment for Major Depression at the VA Medical Center in Asheville, North Carolina by Dr. Joe Jones. I am prescribed Paxil 30 mgs once daily. I also receive Amitriptyline 100 mgs for treatment of Peripheral Neuropathy which is also an antidepressant. In the past I have been given prescriptions of Tofranil and have been in and out of treatment for many years.
Panic Disorder with Agoraphobia and Generalized Anxiety Disorder(Anxiety Disorders 12.06): I have Panic disorder with Agoraphobia and Generalized Anxiety Disorder comorbid to Post-traumatic Stress Disorder.
Occupational Limitations: I suffer panic attacks daily with severe bouts of panic disorder three or four times weekly. I have motor tension, fatigue, anticipatory anxiety, hypervigilance, and hyperactivity of mind and body. I have significant fear of reliving my experiences in Vietnam or when I observe things that remind me of Vietnam, I have panic attacks. It restricts my ability to perform work related functions because of constant ruminations of impending doom, feelings as if bad things will happen, and feelings as if I were still in combat. This anxiety is unmanageable and a source of continuous uncertainly and fear.
I prefer isolation to social activities and restrict my movements to around home and on occasions venture out with my spouse. I have problems with concentration, persistence, and often fail to complete tasks in a timely fashion. I tend to withdraw from situations where there is no possibility of escape, or when I am uncomfortable. If the situation reminds me of my Vietnam experiences, I seek the safety of my home.
Treatment: I receive treatment from the VA Medical Center in Asheville, North Carolina by Dr. Joe Jones. I am prescribed Alprazolam 1 mg five times daily for Panic Disorder with Agoraphobia and Generalized Anxiety Disorder.
Diabetes Type II Herbicide Exposure (Endocrine Disorder 9.00): My diabetes causes problems with dizziness and balance problems. I also have bilateral peripheral neuropathy in both upper and lower extremities. I have numbness, tingling sensations, loss of sensation, cramps, and burning sensations in all extremities. When I sit for long periods of time my extremities become numb (as if they are going to sleep), cramps, and burning sensations. I am unable to grip things, hold items, open jars, lift or carry items, and I constantly drop things. My ability to perform tasks is impaired as I cannot perform keyboard functions as I once did. My hands tend to cramp causing pain and discomfort. If I stand for long periods of time my legs cramp and there is swelling of the ankles. The burning sensations on the bottom of my feet feel as if I am standing on pins and needles.
Treatment: In the past I have seen a Primary Care Physician in the local community. At present, I receive all treatments at the VA Medical Center in Asheville, North Carolina. For Diabetes type II I take Glyuburide and for Peripheral Neuropathy I take Amitriptyline 100 mgs daily and 2500 mcg of
Vitamin B-12 daily.
Hypertension (Cardiovascular System 4.00): I was diagnosed with hypertension in 1991 with consistent readings of 150/106.
Occupational Limitations: Hypertension causes lightheadedness, headaches, weakness, and fatigue. There is a problem with angina pectoris when blood pressure is elevated. Stress and anxiety contribute to the raising of blood pressure. When I become stressed, my chest begins to hurt, and the pain radiates to my upper back, shoulders, and jaw.
Treatment: I currently take Lisinipril 20 mgs and Hydrochlorothiazide 12.5 mgs daily to control blood pressure. Without medications, my blood pressure elevates to abnormal levels. I receive all medications and treatment at the VA Medical Center in Asheville, North Carolina.
Sensorineural Hearing Loss and Tinnitus (SSDI Blue Book: Impairment, Special Senses, and Speech 2.00): I was wounded in Vietnam by a 120 mm rocket round that exploded and penetrated our emplacement. It causes high threshold hearing loss on the right side and I have bilateral tinnitus. I also suffer an ear infection while in Vietnam that has contributed to this disorder.
Treatment: I have undergone an Audiology examination and an ENG at the VA Medical Center in Asheville and Winston-Salem, North Carolina.
Cataracts and Peripapillary Atrophy (Impairment, Special Senses, and Speech 2.00): I was diagnosed with bilateral cataracts and peripapillary atrophy by an Ophthalmologist at the VA Medical Center in Winston-Salem and Asheville, North Carolina.
Occupational Limitations: My problems with cataracts cause light sensitivity, blurred vision, and inability to read (with progressive eye glasses) effectively. My professional occupations require that I have keen visual senses in performing crucial tests and report writing. I have problems seeing screens on computers or viewing detailed information. I often transpose numbers and names to wrong reports. The condition is preoperative and not surgically appropriate. I also have a CDL class B license, but can no longer drive due to visual problems.
Rotator Cuff Damage (Musculoskeletal System 1.00 ): Because of a shell fragmentation wound suffered to the right shoulder, I was thrown against a wall of a bunker jamming my right shoulder. In the past 30 years, I have received various treatments from oral medications, injections, and massage therapy to stop the pain. Recently this injury has been aggravated and limiting my range of motion and ability to hold, grip, or lift items. It has been recommended that I have surgery in both shoulders to alleviate the pain.
Acne Conglobata and Eczema with Residuals (SSDI Blue Book: Skin 8.00): I acquired this skin disease because of Agent Orange exposure during the Vietnam War. This diagnoses was obtained and treated for a long period of time beginning in February of 1968 until I was discharged from the military.
Occupational Limitations: Because of this skin disorder, I have endured pain, scarring, and frequent eruptions, and infections. Often as is the case, these eruptions are spontaneous causing bleeding and discharges. There is a repugnant odor associated with these discharges. The entire body is affected and depending on the location of pustules, it makes it difficult to sit, lean against the back of a chair, causes itching, forms crust, and causes new lesions.
Treatment: While in the military and afterwards, I have had extensive ultraviolet and oral medication treatments for this skin disorder. To date, no treatment has been able to abate the spread of this disease.
In conclusion, I will (or are rated 100% Permanent and Total by the Veterans Administration with a designation of Individual Unemployability. Because of this designation, it is deemed that my medical and mental disorders will not improve in the next 12 months and will likely continue for my lifetime. I am 57-years of age and contend my disabilities are progressing and will not improve. My medical and mental disorders have progressively worsened to the level that I can no longer function in any occupation that I have worked in for many years. Therefore, I request that my claim for SSDI (or VA Compensation) be approved.
John Doe Smith
Patrick W. , Ph.d
Peace be upon you
Physical exam done by Social Security's Contracted Dr
Physical exam done by Social Security's Contracted Dr - Vet Social Security Issues- SSDI SSI - VA Claims Discussions - Veterans Benefits Network - Message Board
SSDI Self-report - Vet Social Security Issues- SSDI SSI - VA Claims Discussions - Veterans Benefits Network - Message Board