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Routine: DVBCQAL3

DVBCQAL3.m

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DVBCQAL3 ;;;ALB-CIOFO/ECF -  AMYOTROPHIC LATERAL SCLEROSIS (ALS) QUESTIONNAIRE ; 5/15/2011

 ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1

 ;

TXT ;

 ;;

 ;; 7. Housebound

 ;;

 ;; a. Is the Veteran substantially confined to his or her dwelling and the

 ;; immediate premises (or if institutionalized, to the ward or clinical areas)?

 ;; ___ Yes   ___ No

 ;; If yes, describe how often per day or week and under what circumstances the

 ;; Veteran is able to leave the home or immediate premises: ___________________

 ;;

 ;; b. If yes, does the Veteran have more than one condition contributing to his

 ;; or her being housebound?

 ;; ___ Yes   ___ No

 ;; If yes, list conditions and describe how each condition contributes to

 ;; causing the Veteran to be housebound:

 ;;

 ;; Condition #1: __________________________________

 ;; Describe how condition #1 contributes to causing the Veteran to be

 ;; housebound: ________________________________________________________________

 ;;

 ;; Condition #2: __________________________________

 ;; Describe how condition #2 contributes to causing the Veteran to be

 ;; housebound: ________________________________________________________________

 ;;

 ;; Condition #3: __________________________________

 ;; Describe how condition #3 contributes to causing the Veteran to be

 ;; housebound: ________________________________________________________________

 ;;

 ;; c. If the Veteran has additional conditions contributing to causing the

 ;; Veteran to be housebound, list using above format: _________________________

 ;;

 ;; ____________________________________________________________________________

 ;;

 ;; 8. Aid & Attendance

 ;;

 ;; a. Is the Veteran able to dress or undress him or herself without

 ;; assistance?

 ;; ___ Yes   ___ No

 ;;     If no, is this limitation caused by the Veteran's ALS?

 ;;     ___ Yes   ___ No

 ;;^TOF^

 ;; b. Does the Veteran have sufficient upper extremity coordination and

 ;; strength to be able to feed him or herself without assistance?

 ;; ___ Yes   ___ No

 ;;     If no, is this limitation caused by the Veteran's ALS?

 ;;     ___ Yes   ___ No

 ;;

 ;; c. Is the Veteran able to attend to the wants of nature (toileting) without

 ;; assistance?

 ;; ___ Yes   ___ No

 ;;     If no, is this limitation caused by the Veteran's ALS?

 ;;     ___ Yes   ___ No

 ;;

 ;; d. Is the Veteran able to bathe him or herself without assistance?

 ;; ___ Yes   ___ No

 ;;     If no, is this limitation caused by the Veteran's ALS?

 ;;     ___ Yes   ___ No

 ;;

 ;; e. Is the Veteran able to keep him or herself ordinarily clean and

 ;; presentable without assistance?

 ;; ___ Yes   ___ No

 ;;     If no, is this limitation caused by the Veteran's ALS?

 ;;     ___ Yes   ___ No

 ;;

 ;; f. Does the Veteran need frequent assistance for adjustment of any special

 ;; prosthetic or orthopedic appliance(s)?

 ;; ___ Yes   ___ No

 ;; If yes, describe: __________________________________________________________

 ;;^TOF^

 ;; NOTE: For VA purposes, "bedridden" will be that condition which actually

 ;; requires that the claimant remain in bed. The fact that claimant has

 ;; voluntarily taken to bed or that a physician has prescribed rest in bed for

 ;; the greater or lesser part of the day to promote convalescence or cure will

 ;; not suffice.

 ;;

 ;; g. Is the Veteran bedridden?

 ;; ___ Yes   ___ No

 ;;     If yes, is it due to the Veteran's ALS?

 ;;     ___ Yes   ___ No

 ;;

 ;; h. Does the Veteran require care and/or assistance on a regular basis due to

 ;; his or her physical and/or mental disabilities in order to protect him or

 ;; herself from the hazards and/or dangers incident to his or her daily

 ;; environment?

 ;; ___ Yes   ___ No

 ;;    If yes, is it due to the Veteran's ALS?

 ;;     ___ Yes   ___ No

 ;;

 ;; i.  List any condition(s), in addition to the Veteran's ALS, that causes any

 ;; of the above limitations: __________________________________________________

 ;;

 ;; 9. Need for higher level (i.e., more skilled) Aid & Attendance (A&A)

 ;;

 ;; Does the Veteran require a higher, more skilled level of A&A?

 ;; ___ Yes   ___ No

 ;;

 ;; NOTE: For VA purposes, this skilled, higher level care includes (but is not

 ;; limited to) health-care services such as physical therapy, administration of

 ;; injections, placement of indwelling catheters, changing of sterile

 ;; dressings, and/or like functions which require professional health-care

 ;; training or the regular supervision of a trained health-care professional to

 ;; perform. In the absence of this higher level of care provided in the home,

 ;; the Veteran would require hospitalization, nursing home care, or other

 ;; residential institutional care.

 ;;^TOF^

 ;; 10. Assistive devices

 ;;

 ;; a. Does the Veteran use any assistive device(s) as a normal mode of

 ;; locomotion, although occasional locomotion by other methods may be possible?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, identify assistive device(s) used (check all that apply and indicate

 ;; frequency):

 ;;

 ;;   ___ Wheelchair  Frequency of use: __ Occasional   __ Regular   __ Constant

 ;;   ___ Brace(s)    Frequency of use: __ Occasional   __ Regular   __ Constant

 ;;   ___ Crutch(es)  Frequency of use: __ Occasional   __ Regular   __ Constant

 ;;   ___ Cane(s)     Frequency of use: __ Occasional   __ Regular   __ Constant

 ;;   ___ Walker      Frequency of use: __ Occasional   __ Regular   __ Constant

 ;;   ___ Other: _______________________________________________________________

 ;;                   Frequency of use: __ Occasional   __ Regular   __ Constant

 ;;

 ;; b. If the Veteran uses any assistive devices, specify the condition and

 ;; identify the assistive device used for each condition: _____________________

 ;;

 ;; ____________________________________________________________________________

 ;;

 ;; 11. Remaining effective function of the extremities

 ;;

 ;; Due to ALS condition, is there functional impairment of an extremity such

 ;; that no effective function remains other than that which would be equally

 ;; well served by an amputation with prosthesis? (Functions of the upper

 ;; extremity include grasping, manipulation, etc., while functions for the

 ;; lower extremity include balance and propulsion, etc.)

 ;;

 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would

 ;;     equally serve the Veteran.

 ;; ___ No

 ;;     If yes, indicate extremity(ies)(check all extremities for which this

 ;;     applies):

 ;;     ___ Right upper   ___ Left upper   ___ Right lower   ___ Left lower

 ;;

 ;;     For each checked extremity, describe loss of effective function,

 ;;     identify the condition causing loss of function, and provide specific

 ;;     examples (brief summary): ______________________________________________

 ;;

 ;; 12. Financial responsibility

 ;;

 ;; In your judgment, is the Veteran able to manage his/her benefit payments in

 ;; his/her own best interest, or able to direct someone else to do so?

 ;; ___ Yes   ___ No

 ;;

 ;; If no, provide rationale: __________________________________________________

 ;;^TOF^

 ;; 13. Diagnostic testing

 ;;

 ;; NOTE: If pulmonary function testing (PFT) is indicated due to respiratory

 ;; disability, and results are in the medical record and reflect the Veteran's

 ;; current respiratory function, repeat testing is not required. DLCO and

 ;; bronchodilator testing is not indicated for a restrictive respiratory

 ;; disability such as that caused by muscle weakness due to ALS.

 ;;

 ;; a. Have PFTs been performed?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, provide most recent results, if available:

 ;;

 ;; FEV-1: ____________ % predicted   Date of test: _____________

 ;; FVC:  _____________ % predicted   Date of test: _____________

 ;; FEV-1/FVC: ________ % predicted   Date of test: _____________

 ;;

 ;; b. If PFTs have been performed, is the flow-volume loop compatible with

 ;; upper airway obstruction?

 ;; ___ Yes   ___ No

 ;;

 ;; c. Are there any other significant diagnostic test findings and/or results?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, provide type of test or procedure, date and results (brief summary):

 ;;

 ;; ____________________________________________________________________________

 ;;

 ;; 14. Functional impact

 ;;

 ;; Does the Veteran's ALS impact his or her ability to work?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, describe the impact of the Veteran's ALS, providing one or more

 ;; examples: __________________________________________________________________

 ;;

 ;; ____________________________________________________________________________

 ;;^TOF^

 ;; 15. Remarks, if any: _______________________________________________________

 ;;

 ;; ____________________________________________________________________________

 ;;

 ;; Physician signature: ____________________________________ Date: ____________

 ;;

 ;; Physician printed name: ____________________________________________________

 ;;

 ;; Medical license #: _________________________________________________________

 ;;

 ;; Physician address: _________________________________________________________

 ;;

 ;; Phone: ____________________________     FAX: _______________________________

 ;;

 ;; NOTE: VA may request additional medical information, including additional

 ;; examinations if necessary to complete VA's review of the Veteran's

 ;; application.

 ;;

 ;;^END^

 Q