9. a.) Documented history of previous mental illness?0 = No 1 = Yes 99 = Unk/not doc
(IF YES, CHOOSE ALL THAT APPLY)
	1 = Depression	2 = Traumatic Brain Injury
3 = Anxiety Disorder	4 = PTSD	5 = Bipolar Disorder
6 = Psychotic Disorder	7 = Substance Abuse Disorder	8 = Personality Disorder
9 = Other _____________
b.) Previous hospitalization for mental health condition? 0 = No 1 = Yes 99 = Unk/not doc
(IF YES, CHOOSE ALL THAT APPLY)
	1 = Depression	2 = Traumatic Brain Injury
3 = Anxiety Disorder	4 = PTSD	5 = Bipolar Disorder
6 = Psychotic Disorder	7 = Substance Abuse Disorder	8 = Personality Disorder
9 = Other _____________
c.) Past suicidal ideation or attempt present? 0 = No 1 = Yes 99 = Unk/not doc
b) If yes, indicate all classes of medications taken.
…First examine Medications Tab.
….Next in each clinic note examine for active medications.
….Next go to Reports, clinical reports, pharmacy, all outpatient medications.
(CHOOSE ALL THAT APPLY)
1 = SSRI	2 = SNRI	3 = Mixed Class	4 = Antipsychotics
5= Mood stabilizers	6=Benzodiazepines	7 = other psychotropic (list ____________)	99 = Unk/not doc
(list specific drugs associated with PTSD Rx)______________________________________________________________
c) Is there evidence for past psychotherapy?	0 = No	1 = Yes	99 = Unk/not doc
(If yes list type of therapy provided or planned (e.g. PE, CBT, CPT, Supportive)____________________________)
10. Psychiatric history
1. First look on cover sheet for diagnoses – ensure that date of diagnosis falls within specified time frame if no MI
2. Look in primary care notes under Past Medical History section if no MI
3. Examine D/C summary section and look for admissions to psychiatry service
Documented history of previous mental illness?0 = No 1 = Yes 99 = Unk/not doc
(IF YES, CHOOSE ALL THAT APPLY)
	1 = Depression	2 = Traumatic Brain Injury
3 = Anxiety Disorder	4 = PTSD	5 = Bipolar Disorder
6 = Psychotic Disorder	7 = Substance Abuse Disorder	8 = Personality Disorder
9 = Other _____________
b.) Previous hospitalization for mental health condition? 0 = No 1 = Yes 99 = Unk/not doc
(IF YES, CHOOSE ALL THAT APPLY)
	1 = Depression	2 = Traumatic Brain Injury
3 = Anxiety Disorder	4 = PTSD	5 = Bipolar Disorder
6 = Psychotic Disorder	7 = Substance Abuse Disorder	8 = Personality Disorder
9 = Other _____________
c.) Past suicidal ideation or attempt present? 0 = No 1 = Yes 99 = Unk/not doc
	FINAL ASSESSMENT
1. Has a past or current diagnosis of PTSD		_____________
2. Has a past or current diagnosis of Depression		_____________
Score 1 – 5
3. Is currently being managed for PTSD and being monitored for symptoms of PTSD			_____________
4. Is currently being managed for PTSD and being monitored for symptoms of Depression			_____________
Score 1 – 5
5. Is currently being treated for PTSD with medications		_____________
6. Is currently being treated for Depression with medications		_____________
Score 1 – 5
7. Is currently being treated for PTSD with behavioral therapies		_____________
8. Is currently being treated for Depression with behavioral therapies		_____________
Score 1 – 5

Each of the four parameters will be assessed using a 5‐point Likert scale with the following categories: 1=definitely; 2=highly likely; 3=possibly; 4=highly unlikely; and 5=definitely not.