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MST-CLAIM POST-TRAUMATIC STRESS DISORDER (PTSD) SECONDARY TO PERSONAL ASSAULT

    SECTION I: VETERAN'S IDENTIFICATION INFORMATION








    SECTION II: STRESSFUL INCIDENT(S)




    SECTION II: STRESSFUL INCIDENT(S) (Continued)

    9. OTHER SOURCES OF INFORMATION: Identify any other sources (military or non-military) that may provide information concerning the incident in Items 9A through 9F. If you reported the incident to military or civilian authorities or sought help from a rape crisis center, counseling facility, or health clinic, etc., please provide the names and addresses and we will assist you in getting the information. If the source provided treatment and you would like us to obtain the treatment records, complete and sign VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA) and VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), and fill in each provider. If you confided in roommates, family members, chaplains, clergy, or fellow service persons, you may want to ask them for a statement concerning their knowledge of the incident. Use VA Form 21-10210, Lay/Witness Statement, to provide these statements to the VA. These statements will help us in deciding your claim. Other sources of information also include personal diaries or journals. VA forms are available at www.va.gov/vaforms.




    MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)








    MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)








    MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)





    SECTION II: STRESSFUL INCIDENT(S) (Continued)

    0. Please provide in the space below any other information that you feel is important for us to know that may help your claim. The following
    are some examples of behavioral changes that you may have experienced following the incident(s):
    • visits to a medical or counseling clinic or dispensary without a specific diagnosis or specific ailment
    • sudden requests for a change in occupational series or duty assignment
    • increased use of leave without an apparent reason
    • changes in performance and performance evaluations
    • episodes of depression, panic attacks, or anxiety without an identifiable cause
    • increased or decreased use of prescription medications
    • increased use of over-the-counter medications
    • substance abuse such as alcohol or drugs
    • increased disregard for military or civilian authority
    • obsessive behavior such as overeating or under eating
    • pregnancy tests around the time of the incident
    • tests for HIV or sexually transmitted diseases
    • unexplained economic or social behavior changes

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