My Trauma and PTSD Evaluation

The below examination is from my health record
located at the Veterans Hospital, Gainesville, Fl.

TRAUMA/PTSD SCREEN:

Some people have had terrible experiences that others never go through,
such as:
- being attacked - no
- being sexually assaulted or raped - no
- being in a flood or natural disaster - no
- being in combat - yes
- being in a bad accident - no
- being threatened with a weapon - yes
- seeing someone badly injured or killed - yes

(a) Did any of these experiences ever happen to you? (X)yes ()no ()N/A
If you answered "no" to question a, skip questions b, c, and d.

(b) In the past month, have you been bothered by repeated, disturbing
memories, thoughts or images of one or more of the stressful events
experienced above? ()yes (X)no ()N/A

(c) In the past month, have you felt distant or cut off from other people?
()yes (X)no ()N/A

(d) In the past month, have you been "super alert" or watchful or on
guard? ()yes (X)no ()N/A

Scoring: If patient answers affirmatively to question a and endorses ONE
of the subsequent questions (b, c, or d) refer to a mental health

professional for further evaluation and treatment of probable PTSD.

DEPRESSION SCREEN

1. During the past month, have you often been bothered by feeling down,
depressed, or hopeless? ()yes (X)no

2. During the past month, have you often been bothered by little interest
or pleasure in doing things? ()yes (X)no

A positive test result = a yes response to either question.
LIVING ENVIRONMENT SCREEN


PATIENT NAME AND ADDRESS
MORRISON, ALDEN
GAINESVILLE, FLORIDA 32609

VISTA Electronic Medical Documentation

Printed at N. FLORIDA/S. GEORGIA VHS
Page 459

() Home/apartment with family
() Home/apartment alone
() Structured living environment (i.e. Oxford House, Assisted Living)
() Shelter or transient home
(X) Homeless

ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT)

1. How often do you have a drink containing alcohol?

( )0. Never
( )1. Monthly or less
( )2. Two to four times a month
( )3. Two to three times a week
(X )4. Four or more times a week

2. How many drinks containing alcohol do you have on a typical day when you
are drinking?

( )0. 1 or 2
( )1. 3 or 4
( )2. 5 or 6
( )3. 7-9
(X )4. 10 or more

3. How often do you have six or more drinks on one occasion?

( )0. Never
( )1. Less than monthly
( )2. Monthly
( )3. Weekly
(X )4. Daily or almost daily

4. How often during the last year have you found that you were not able to
stop drinking once you had started?

( )0. Never
( )1. Less than monthly
( )2. Monthly
( )3. Weekly
(X )4. Daily or almost daily

5. How often during the past year have you failed to do what was normally
expected from you because of drinking?

( )0. Never
( )1. Less than monthly
( )2. Monthly
(X )3. Weekly
( )4. Daily or almost daily

MORRISON, ALDEN
GAINESVILLE, FLORIDA 32609

6. How often during the last year have you needed a first drink in the
morning to get yourself going after a heavy drinking session?

( )0. Never
( )1. Less than monthly
( )2. Monthly
( )3. Weekly
(X )4. Daily or almost daily

7. How often during the last year have you had a feeling of guilt or
remorse after drinking?

(X )0. Never
( )1. Less than monthly
( )2. Monthly
( )3. Weekly
( )4. Daily or almost daily

8. How often during the last year have you been unable to remember what
happened the night before because you had been drinking?

(X )0. Never
( )1. Less than monthly
( )2. Monthly
( )3. Weekly
( )4. Daily or almost daily

9. Have you or someone else been injured as a result of your drinking?

(X )0. No
( )2. Yes, but not in the last year
( )4. Yes, during the last year

10. How often has a friend, relative, doctor, or other health worker been
concerned about your drinking or suggested you cut down?

( )0. Never
( )1. Less than monthly
(X )2. About once a month
( )3. About once a week
( )4. Several times a week

Total Score= 25
A score of 8 or above is considered indicative of a clinical alcohol
disorder, and further evaluation should be performed.
/es/ A. D.
RN, C
Signed: 11/30/2007 10:16

LOCAL TITLE: SATT RESIDENTIAL INITIAL NURSING ASSESSMENT (T)
STANDARD TITLE: NURSING NOTE

VISTA Electronic Medical Documentation

Page 461
DATE OF NOTE: NOV 30, 2007@09:43 ENTRY DATE: NOV 30, 2007@09:43:46
AUTHOR: D, L EXP COSIGNER:
URGENCY: STATUS: COMPLETED

This is a 64 year old, FEB 4,1943, DIVORCED,MALE who was admitted
to SARRTP from the Gainesville Salvation Army where he has resided for 1 1/2
months. Prior to this, vet lived in Tallahassee, FL in an apartment x 1 1/2yrs.
Vet put his belongings in storage and came to Gainesville for substance abuse
treatment. Upon arrival to Gainesville vet entered into Ambulatory Detox and
completed x 1wk. Vet referred to SARRTP by: Fred, MSW and Irma
, CAP. Vet will be followed by Ms. Irma

SARRTP. DOC - Alcohol. Vet denies h/o substance abuse treatment.

1. INITIAL NURSING ASSESSMENT

RATED DISABILITIES - NONE FOUND
___________________________________________________________________
Height: 68 in [172.7 cm] (11/30/2007 08:57)
Weight: 252 lb [114.5 kg] (11/30/2007 08:57)
Temperature: 98.2 F [36.8 C] (11/30/2007 08:57)
B/P: 130/79 (11/30/2007 08:57)
Pulse: 66 (11/30/2007 08:57)
Respiration: 18 (11/30/2007 08:57)
___________________________________________________________________
BAL: 0.0 Urine DS Sent: ()Yes ()No (X)Pending
__________________________________________________________________
NUTRITIONAL ASSESSMENT:
Appetite: ()Very poor ()Probably inadequate (X)Adequate
()Excellent
History:
Current diet: regular
Religious/Ethic/Cultural Food Preferences: denies
Appetite - good
Recent weight loss/gain - stable
Difficulty Chewing/Swallowing - denies
___________________________________________________________________
Allergies: Patient has answered NKA
___________________________________________________________________
Reason for Admission: Substance abuse treatment:

PATIENT NAME AND ADDRESS
MORRISON, ALDEN
GAINESVILLE, FLORIDA 32609

I was now in residential treatment in the Veterans
Hospital, Gainesville, Fl

Author: Alden Morrison

___________________________________________________________________

Bashing Alcoholics Anonymous - Veteran Confused

I recently came across a program called
Rational Recovery. The owner of this site
sure bashes the Alcoholics Anonymous
program. The program relies on making
affirmative and positive statements and
reading them aloud as many times a day as
you can and therefore breaking the habit
of overindulgence of alcohol. According
to the owner of this site, it is not a
disease but an overindulgence, on the
alcoholics and drug addicts part. I have
no issue with this, in my case it seems
to me that it does not matter as long as
I take responsibility for my own actions
and not blame it on a disease or over-
indulgence, I blame it on what it is, I
am a drunk.

Basically what he prescribes is auto-
suggestion, which became very popular
with Napoleon Hills book ("Think and
Grow Rich") back in the 50s. I have
read the book and it is a great book and
works on anything you have a burning
desire to do. You can buy a used copy
on ebay for a couple of bucks.

Where Rational Recovery misses the boat
on the Alcoholics Anonymous program and
believe me, it is not perfect, is the fellow-
ship before and after meetings. I was new
in Gainesville, Fl and now know lots of
sober people to hang out with. The owner
of Rational Recovery on his website declares,
no more meetings, well I stayed at home,
drank, got drunk and isolated. Isolation,
is that not deadly for the alcoholic? Oh yes,
you can chat online, but really, is that not
still isolation?. I did, I drank chatted with
people I should not have been chatting
with and drank some more.

Another point is during my day when someone
irritates me, or I am rude to a stranger, give my
finger to another driver, call him or her an idiot,
then my conscience takes over and I feel bad
about it all and it's in me. I can go to a meeting
and unload it all and feel much better for
telling everyone what kind of idiot I am. You
know the Catholic Religion, about 200 million
world wide have a thing called confessional which
every Catholic has to do every year, I do not
know how many times, but I do know that they
must feel pretty good after doing it, closer
to there God, well after telling everyone about
my being an idiot on any given day makes me
feel good and closer to my Higher Power which
is also God. You don't get that with Rational
Recovery.

I include positive statements and reaffirmation's
in my program of recovery, but I still chose to
use the AA program as a way of life. It keeps
life interesting for me and most important
keeps me sober and keeps me working on
myself as a human being, I am actually a
pleasant guy to know now, so I say.

A last point, I don't know of to many
organizations that try to build a member-
ship by bashing another organization, even
a mediocre sales person knows this after
all, Rational Recovery is a business.

Author: Alden Morrison

Step Two - A Power Greater Than Myself

Step Two tells me there is a power greater
than ourselves and informs me, that I
am not going to fix my alcohol problem
by myself. The same mind that created
the problem, can't fix it on its own.

I came to believe that doing the things I
did like driving intoxicated, the affairs
I had, the yelling and screaming, the
lying that I believed, the excuses, losing
money, taking money from my family,
the bad business decisions, forgetting
where I parked the car, forgetting
where I had been, who I had talked
to, just to name a few was insane, a
sane person would not do what I had
done. I was on a path of self destruc-
tion that was ruining my health, cost
me my business and my family and I
still did not get the picture and con-
tinued to drink, you could say that I
was not playing with a full deck of
cards. I was insane.

I remember reading Think and Grow
Rich by Napoleon Hill and the Great-
est Story Ever Told by Earl Nighting-
ale that said we have a power that is
greater than ourselves and if we used
it, our lives would be enriched. I have
chosen to call on that power and I
call him God.

Now I have real hope that I can recover
I have an open mind about it, I don't
doubt my Higher Power and there-
fore have faith and as long as I keep
faith, I know, I will be alright.

Author: Alden Morrison

Diagnosis: Substances Abuse

One of the classes I attend:

Problem: Lack of effective knowledge of the
addictive and recovery process.

Intervention: This class explored the latest
definition of addiction along with several
instruments designed to distinguish the difference
between the abuse vs. dependence on a substance.
The definition describes addiction as a primary,
chronic, progressive illness, with a compulsive
element, that if left untreated can cause death.
This definition was discussed in some detail. The
difference between a problem drinker and an
alcoholic was also a topic of the group. Many
group members related some personal history as to their use or abuse of substances.

Evaluation: Vet appeared alert and interacted
appropriately during group.

All group members who use tobacco products were
encouraged to discuss with case manager the
possibility of referral to smoking cessation
services.

/es/ Rick Murrhee, MHS
Addiction Therapist

I enjoyed the class and learned a lot about
myself in my fight to stay sober

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