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Routine: DVBCQAL3

DVBCQAL3.m

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  1. DVBCQAL3 ;;;ALB-CIOFO/ECF - AMYOTROPHIC LATERAL SCLEROSIS (ALS) QUESTIONNAIRE ; 5/15/2011
  1. ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
  1. ;
  1. TXT ;
  1. ;;
  1. ;; 7. Housebound
  1. ;;
  1. ;; a. Is the Veteran substantially confined to his or her dwelling and the
  1. ;; immediate premises (or if institutionalized, to the ward or clinical areas)?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe how often per day or week and under what circumstances the
  1. ;; Veteran is able to leave the home or immediate premises: ___________________
  1. ;;
  1. ;; b. If yes, does the Veteran have more than one condition contributing to his
  1. ;; or her being housebound?
  1. ;; ___ Yes ___ No
  1. ;; If yes, list conditions and describe how each condition contributes to
  1. ;; causing the Veteran to be housebound:
  1. ;;
  1. ;; Condition #1: __________________________________
  1. ;; Describe how condition #1 contributes to causing the Veteran to be
  1. ;; housebound: ________________________________________________________________
  1. ;;
  1. ;; Condition #2: __________________________________
  1. ;; Describe how condition #2 contributes to causing the Veteran to be
  1. ;; housebound: ________________________________________________________________
  1. ;;
  1. ;; Condition #3: __________________________________
  1. ;; Describe how condition #3 contributes to causing the Veteran to be
  1. ;; housebound: ________________________________________________________________
  1. ;;
  1. ;; c. If the Veteran has additional conditions contributing to causing the
  1. ;; Veteran to be housebound, list using above format: _________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; 8. Aid & Attendance
  1. ;;
  1. ;; a. Is the Veteran able to dress or undress him or herself without
  1. ;; assistance?
  1. ;; ___ Yes ___ No
  1. ;; If no, is this limitation caused by the Veteran's ALS?
  1. ;; ___ Yes ___ No
  1. ;;^TOF^
  1. ;; b. Does the Veteran have sufficient upper extremity coordination and
  1. ;; strength to be able to feed him or herself without assistance?
  1. ;; ___ Yes ___ No
  1. ;; If no, is this limitation caused by the Veteran's ALS?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; c. Is the Veteran able to attend to the wants of nature (toileting) without
  1. ;; assistance?
  1. ;; ___ Yes ___ No
  1. ;; If no, is this limitation caused by the Veteran's ALS?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; d. Is the Veteran able to bathe him or herself without assistance?
  1. ;; ___ Yes ___ No
  1. ;; If no, is this limitation caused by the Veteran's ALS?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; e. Is the Veteran able to keep him or herself ordinarily clean and
  1. ;; presentable without assistance?
  1. ;; ___ Yes ___ No
  1. ;; If no, is this limitation caused by the Veteran's ALS?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; f. Does the Veteran need frequent assistance for adjustment of any special
  1. ;; prosthetic or orthopedic appliance(s)?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe: __________________________________________________________
  1. ;;^TOF^
  1. ;; NOTE: For VA purposes, "bedridden" will be that condition which actually
  1. ;; requires that the claimant remain in bed. The fact that claimant has
  1. ;; voluntarily taken to bed or that a physician has prescribed rest in bed for
  1. ;; the greater or lesser part of the day to promote convalescence or cure will
  1. ;; not suffice.
  1. ;;
  1. ;; g. Is the Veteran bedridden?
  1. ;; ___ Yes ___ No
  1. ;; If yes, is it due to the Veteran's ALS?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; h. Does the Veteran require care and/or assistance on a regular basis due to
  1. ;; his or her physical and/or mental disabilities in order to protect him or
  1. ;; herself from the hazards and/or dangers incident to his or her daily
  1. ;; environment?
  1. ;; ___ Yes ___ No
  1. ;; If yes, is it due to the Veteran's ALS?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; i. List any condition(s), in addition to the Veteran's ALS, that causes any
  1. ;; of the above limitations: __________________________________________________
  1. ;;
  1. ;; 9. Need for higher level (i.e., more skilled) Aid & Attendance (A&A)
  1. ;;
  1. ;; Does the Veteran require a higher, more skilled level of A&A?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; NOTE: For VA purposes, this skilled, higher level care includes (but is not
  1. ;; limited to) health-care services such as physical therapy, administration of
  1. ;; injections, placement of indwelling catheters, changing of sterile
  1. ;; dressings, and/or like functions which require professional health-care
  1. ;; training or the regular supervision of a trained health-care professional to
  1. ;; perform. In the absence of this higher level of care provided in the home,
  1. ;; the Veteran would require hospitalization, nursing home care, or other
  1. ;; residential institutional care.
  1. ;;^TOF^
  1. ;; 10. Assistive devices
  1. ;;
  1. ;; a. Does the Veteran use any assistive device(s) as a normal mode of
  1. ;; locomotion, although occasional locomotion by other methods may be possible?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, identify assistive device(s) used (check all that apply and indicate
  1. ;; frequency):
  1. ;;
  1. ;; ___ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
  1. ;; ___ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
  1. ;; ___ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
  1. ;; ___ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
  1. ;; ___ Walker Frequency of use: __ Occasional __ Regular __ Constant
  1. ;; ___ Other: _______________________________________________________________
  1. ;; Frequency of use: __ Occasional __ Regular __ Constant
  1. ;;
  1. ;; b. If the Veteran uses any assistive devices, specify the condition and
  1. ;; identify the assistive device used for each condition: _____________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; 11. Remaining effective function of the extremities
  1. ;;
  1. ;; Due to ALS condition, is there functional impairment of an extremity such
  1. ;; that no effective function remains other than that which would be equally
  1. ;; well served by an amputation with prosthesis? (Functions of the upper
  1. ;; extremity include grasping, manipulation, etc., while functions for the
  1. ;; lower extremity include balance and propulsion, etc.)
  1. ;;
  1. ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
  1. ;; equally serve the Veteran.
  1. ;; ___ No
  1. ;; If yes, indicate extremity(ies)(check all extremities for which this
  1. ;; applies):
  1. ;; ___ Right upper ___ Left upper ___ Right lower ___ Left lower
  1. ;;
  1. ;; For each checked extremity, describe loss of effective function,
  1. ;; identify the condition causing loss of function, and provide specific
  1. ;; examples (brief summary): ______________________________________________
  1. ;;
  1. ;; 12. Financial responsibility
  1. ;;
  1. ;; In your judgment, is the Veteran able to manage his/her benefit payments in
  1. ;; his/her own best interest, or able to direct someone else to do so?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, provide rationale: __________________________________________________
  1. ;;^TOF^
  1. ;; 13. Diagnostic testing
  1. ;;
  1. ;; NOTE: If pulmonary function testing (PFT) is indicated due to respiratory
  1. ;; disability, and results are in the medical record and reflect the Veteran's
  1. ;; current respiratory function, repeat testing is not required. DLCO and
  1. ;; bronchodilator testing is not indicated for a restrictive respiratory
  1. ;; disability such as that caused by muscle weakness due to ALS.
  1. ;;
  1. ;; a. Have PFTs been performed?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, provide most recent results, if available:
  1. ;;
  1. ;; FEV-1: ____________ % predicted Date of test: _____________
  1. ;; FVC: _____________ % predicted Date of test: _____________
  1. ;; FEV-1/FVC: ________ % predicted Date of test: _____________
  1. ;;
  1. ;; b. If PFTs have been performed, is the flow-volume loop compatible with
  1. ;; upper airway obstruction?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; c. Are there any other significant diagnostic test findings and/or results?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, provide type of test or procedure, date and results (brief summary):
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; 14. Functional impact
  1. ;;
  1. ;; Does the Veteran's ALS impact his or her ability to work?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, describe the impact of the Veteran's ALS, providing one or more
  1. ;; examples: __________________________________________________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;^TOF^
  1. ;; 15. Remarks, if any: _______________________________________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; Physician signature: ____________________________________ Date: ____________
  1. ;;
  1. ;; Physician printed name: ____________________________________________________
  1. ;;
  1. ;; Medical license #: _________________________________________________________
  1. ;;
  1. ;; Physician address: _________________________________________________________
  1. ;;
  1. ;; Phone: ____________________________ FAX: _______________________________
  1. ;;
  1. ;; NOTE: VA may request additional medical information, including additional
  1. ;; examinations if necessary to complete VA's review of the Veteran's
  1. ;; application.
  1. ;;
  1. ;;^END^
  1. Q