IPE Example
2025
Mental Disorders Evaluation and Independent Medical Opinion
Patient / Veteran Last Name
First Name
Jason
Phone Number
Date of Birth
Social Security Number
If the Veteran experiences a mental health emergency during the interview, please terminate the interview and obtain help, using local resources as appropriate. You may also contact the Veterans Crisis Line at 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the Veteran to emergency care.
1. Diagnostic Summary
This section was completed based on the current examination and clinical findings that conforms to DSM-5 criteria.
Has the patient ever been diagnosed with Mental Disorder?
No
2. Current Diagnoses
Diagnosis #1:
Other Specified Trauma- and Stressor-Related Disorder
ICD Code:
Comments, If Any:
The veteran indicated a high likelihood of a trauma or stressor related disorder. His symptoms are consistent with a chronic stress response rooted in service-connected trauma.
Diagnosis #2:
Adjustment Disorder with mixed anxiety and depressed mood
ICD Code:
Comments, If Any:
The veteran completed self-report assessments to evaluate anxiety and depressive symptoms and his anxiety and depressive symptoms. His responses indicate the presence of severe
Medical Diagnoses (to include TBI):
Hiatal hernia (service connected)
ICD Code:
3. Multiple Diagnosis
Does the patient have more than one mental disorder diagnosed?
Yes
Is it possible to differentiate what symptom(s)/is/are attributable to each diagnosis?
No
Provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis:
4. Service-Connected Conditions
Are there any service-connected conditions?
Yes
Please list and document source(s) (e.g., VA form, medical records, self report):
5. Occupational and Social Impairment
Which of the Following Best Describes the Veteran's Level of Occupational and Social Impairment With Regards to All Mental Diagnoses?
Occupational and social impairment with deficiencies in most areas (work, school, family relationships, judgment, thinking, and/or mood)
For the Indicated Level of
Occupational and Social Impairment,
Is It Possible to Differentiate What
Portion of the Occupational and Social
Impairment Indicated Above Is
Caused by Each Mental Disorder?
Occupational and Social Impairment,
Is It Possible to Differentiate What
Portion of the Occupational and Social
Impairment Indicated Above Is
Caused by Each Mental Disorder?
No
Provide reason that it is not possible to differentiate what portion of each symptoms is attributable to each diagnosis:
The diagnoses are interconnected, with the predominant source of his current impairments attributed to a mood disorder and pain, given the duration of occupational and social impairment exceeding six months.
6. Clinical Findings
If Any Records (Evidence) Were Reviewed, Please List: