Please read the following carefully. Your signature below indicates that you have read and agreed to the following conditions:

This evaluation has been requested by your case manager at the Veteran Benefits Administration (VBA). The information obtained during this evaluation is for the purpose of helping VBA make a determination in your disability application. This evaluation does not constitute mental health treatment and it does not establish a doctor-patient relationship between the evaluator and the disability claimant.

Your participation in this evaluation is voluntary; you may decline to participate at all or choose to terminate the evaluation at any point in time. You may also choose to not answer certain questions. I do not know how your failure to participate in this evaluation will affect your disability application.

ALL information obtained during this evaluation will be released to VBA. A copy of the report may be obtained by contacting your case manager at VBA. I cannot release the report directly to you. VBA has a specific process for releasing records.

The information obtained during this evaluation will not be shared with anyone outside of VBA, except under the following circumstances:

• You report that a child or vulnerable adult is being abused.
• You report that you plan to take some action to seriously harm yourself or end your own life.
• You report that you have plans to commit murder.
• You are a health care provider and have problems with substance use or mental illness which could impact your care of your patients.

Instructions: This questionnaire consists of 21 groups of statements. Please read each group of statements carefully, and then pick out the one statement in each group that best describes the way you have been feeling during the past two weeks, including today. Circle the number beside the statement you have picked. If several statements in the group seem to apply equally well, circle the highest number for that group. Be sure that you do not choose more than one statement for any group, including Item 16 (Changes in Sleeping Pattern) or Item 18 (Changes in Appetite).

Instructions: This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs. Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please circle only one response.

Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.

Instructions: Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom.