- 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
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQAL3 9585 printed Feb 18, 2025@23:11:58 Page 2
- DVBCQAL3 ;;;ALB-CIOFO/ECF - AMYOTROPHIC LATERAL SCLEROSIS (ALS) QUESTIONNAIRE ; 5/15/2011
- +1 ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
- +2 ;
- TXT ;
- +1 ;;
- +2 ;; 7. Housebound
- +3 ;;
- +4 ;; a. Is the Veteran substantially confined to his or her dwelling and the
- +5 ;; immediate premises (or if institutionalized, to the ward or clinical areas)?
- +6 ;; ___ Yes ___ No
- +7 ;; If yes, describe how often per day or week and under what circumstances the
- +8 ;; Veteran is able to leave the home or immediate premises: ___________________
- +9 ;;
- +10 ;; b. If yes, does the Veteran have more than one condition contributing to his
- +11 ;; or her being housebound?
- +12 ;; ___ Yes ___ No
- +13 ;; If yes, list conditions and describe how each condition contributes to
- +14 ;; causing the Veteran to be housebound:
- +15 ;;
- +16 ;; Condition #1: __________________________________
- +17 ;; Describe how condition #1 contributes to causing the Veteran to be
- +18 ;; housebound: ________________________________________________________________
- +19 ;;
- +20 ;; Condition #2: __________________________________
- +21 ;; Describe how condition #2 contributes to causing the Veteran to be
- +22 ;; housebound: ________________________________________________________________
- +23 ;;
- +24 ;; Condition #3: __________________________________
- +25 ;; Describe how condition #3 contributes to causing the Veteran to be
- +26 ;; housebound: ________________________________________________________________
- +27 ;;
- +28 ;; c. If the Veteran has additional conditions contributing to causing the
- +29 ;; Veteran to be housebound, list using above format: _________________________
- +30 ;;
- +31 ;; ____________________________________________________________________________
- +32 ;;
- +33 ;; 8. Aid & Attendance
- +34 ;;
- +35 ;; a. Is the Veteran able to dress or undress him or herself without
- +36 ;; assistance?
- +37 ;; ___ Yes ___ No
- +38 ;; If no, is this limitation caused by the Veteran's ALS?
- +39 ;; ___ Yes ___ No
- +40 ;;^TOF^
- +41 ;; b. Does the Veteran have sufficient upper extremity coordination and
- +42 ;; strength to be able to feed him or herself without assistance?
- +43 ;; ___ Yes ___ No
- +44 ;; If no, is this limitation caused by the Veteran's ALS?
- +45 ;; ___ Yes ___ No
- +46 ;;
- +47 ;; c. Is the Veteran able to attend to the wants of nature (toileting) without
- +48 ;; assistance?
- +49 ;; ___ Yes ___ No
- +50 ;; If no, is this limitation caused by the Veteran's ALS?
- +51 ;; ___ Yes ___ No
- +52 ;;
- +53 ;; d. Is the Veteran able to bathe him or herself without assistance?
- +54 ;; ___ Yes ___ No
- +55 ;; If no, is this limitation caused by the Veteran's ALS?
- +56 ;; ___ Yes ___ No
- +57 ;;
- +58 ;; e. Is the Veteran able to keep him or herself ordinarily clean and
- +59 ;; presentable without assistance?
- +60 ;; ___ Yes ___ No
- +61 ;; If no, is this limitation caused by the Veteran's ALS?
- +62 ;; ___ Yes ___ No
- +63 ;;
- +64 ;; f. Does the Veteran need frequent assistance for adjustment of any special
- +65 ;; prosthetic or orthopedic appliance(s)?
- +66 ;; ___ Yes ___ No
- +67 ;; If yes, describe: __________________________________________________________
- +68 ;;^TOF^
- +69 ;; NOTE: For VA purposes, "bedridden" will be that condition which actually
- +70 ;; requires that the claimant remain in bed. The fact that claimant has
- +71 ;; voluntarily taken to bed or that a physician has prescribed rest in bed for
- +72 ;; the greater or lesser part of the day to promote convalescence or cure will
- +73 ;; not suffice.
- +74 ;;
- +75 ;; g. Is the Veteran bedridden?
- +76 ;; ___ Yes ___ No
- +77 ;; If yes, is it due to the Veteran's ALS?
- +78 ;; ___ Yes ___ No
- +79 ;;
- +80 ;; h. Does the Veteran require care and/or assistance on a regular basis due to
- +81 ;; his or her physical and/or mental disabilities in order to protect him or
- +82 ;; herself from the hazards and/or dangers incident to his or her daily
- +83 ;; environment?
- +84 ;; ___ Yes ___ No
- +85 ;; If yes, is it due to the Veteran's ALS?
- +86 ;; ___ Yes ___ No
- +87 ;;
- +88 ;; i. List any condition(s), in addition to the Veteran's ALS, that causes any
- +89 ;; of the above limitations: __________________________________________________
- +90 ;;
- +91 ;; 9. Need for higher level (i.e., more skilled) Aid & Attendance (A&A)
- +92 ;;
- +93 ;; Does the Veteran require a higher, more skilled level of A&A?
- +94 ;; ___ Yes ___ No
- +95 ;;
- +96 ;; NOTE: For VA purposes, this skilled, higher level care includes (but is not
- +97 ;; limited to) health-care services such as physical therapy, administration of
- +98 ;; injections, placement of indwelling catheters, changing of sterile
- +99 ;; dressings, and/or like functions which require professional health-care
- +100 ;; training or the regular supervision of a trained health-care professional to
- +101 ;; perform. In the absence of this higher level of care provided in the home,
- +102 ;; the Veteran would require hospitalization, nursing home care, or other
- +103 ;; residential institutional care.
- +104 ;;^TOF^
- +105 ;; 10. Assistive devices
- +106 ;;
- +107 ;; a. Does the Veteran use any assistive device(s) as a normal mode of
- +108 ;; locomotion, although occasional locomotion by other methods may be possible?
- +109 ;; ___ Yes ___ No
- +110 ;;
- +111 ;; If yes, identify assistive device(s) used (check all that apply and indicate
- +112 ;; frequency):
- +113 ;;
- +114 ;; ___ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
- +115 ;; ___ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
- +116 ;; ___ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
- +117 ;; ___ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
- +118 ;; ___ Walker Frequency of use: __ Occasional __ Regular __ Constant
- +119 ;; ___ Other: _______________________________________________________________
- +120 ;; Frequency of use: __ Occasional __ Regular __ Constant
- +121 ;;
- +122 ;; b. If the Veteran uses any assistive devices, specify the condition and
- +123 ;; identify the assistive device used for each condition: _____________________
- +124 ;;
- +125 ;; ____________________________________________________________________________
- +126 ;;
- +127 ;; 11. Remaining effective function of the extremities
- +128 ;;
- +129 ;; Due to ALS condition, is there functional impairment of an extremity such
- +130 ;; that no effective function remains other than that which would be equally
- +131 ;; well served by an amputation with prosthesis? (Functions of the upper
- +132 ;; extremity include grasping, manipulation, etc., while functions for the
- +133 ;; lower extremity include balance and propulsion, etc.)
- +134 ;;
- +135 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
- +136 ;; equally serve the Veteran.
- +137 ;; ___ No
- +138 ;; If yes, indicate extremity(ies)(check all extremities for which this
- +139 ;; applies):
- +140 ;; ___ Right upper ___ Left upper ___ Right lower ___ Left lower
- +141 ;;
- +142 ;; For each checked extremity, describe loss of effective function,
- +143 ;; identify the condition causing loss of function, and provide specific
- +144 ;; examples (brief summary): ______________________________________________
- +145 ;;
- +146 ;; 12. Financial responsibility
- +147 ;;
- +148 ;; In your judgment, is the Veteran able to manage his/her benefit payments in
- +149 ;; his/her own best interest, or able to direct someone else to do so?
- +150 ;; ___ Yes ___ No
- +151 ;;
- +152 ;; If no, provide rationale: __________________________________________________
- +153 ;;^TOF^
- +154 ;; 13. Diagnostic testing
- +155 ;;
- +156 ;; NOTE: If pulmonary function testing (PFT) is indicated due to respiratory
- +157 ;; disability, and results are in the medical record and reflect the Veteran's
- +158 ;; current respiratory function, repeat testing is not required. DLCO and
- +159 ;; bronchodilator testing is not indicated for a restrictive respiratory
- +160 ;; disability such as that caused by muscle weakness due to ALS.
- +161 ;;
- +162 ;; a. Have PFTs been performed?
- +163 ;; ___ Yes ___ No
- +164 ;;
- +165 ;; If yes, provide most recent results, if available:
- +166 ;;
- +167 ;; FEV-1: ____________ % predicted Date of test: _____________
- +168 ;; FVC: _____________ % predicted Date of test: _____________
- +169 ;; FEV-1/FVC: ________ % predicted Date of test: _____________
- +170 ;;
- +171 ;; b. If PFTs have been performed, is the flow-volume loop compatible with
- +172 ;; upper airway obstruction?
- +173 ;; ___ Yes ___ No
- +174 ;;
- +175 ;; c. Are there any other significant diagnostic test findings and/or results?
- +176 ;; ___ Yes ___ No
- +177 ;;
- +178 ;; If yes, provide type of test or procedure, date and results (brief summary):
- +179 ;;
- +180 ;; ____________________________________________________________________________
- +181 ;;
- +182 ;; 14. Functional impact
- +183 ;;
- +184 ;; Does the Veteran's ALS impact his or her ability to work?
- +185 ;; ___ Yes ___ No
- +186 ;;
- +187 ;; If yes, describe the impact of the Veteran's ALS, providing one or more
- +188 ;; examples: __________________________________________________________________
- +189 ;;
- +190 ;; ____________________________________________________________________________
- +191 ;;^TOF^
- +192 ;; 15. Remarks, if any: _______________________________________________________
- +193 ;;
- +194 ;; ____________________________________________________________________________
- +195 ;;
- +196 ;; Physician signature: ____________________________________ Date: ____________
- +197 ;;
- +198 ;; Physician printed name: ____________________________________________________
- +199 ;;
- +200 ;; Medical license #: _________________________________________________________
- +201 ;;
- +202 ;; Physician address: _________________________________________________________
- +203 ;;
- +204 ;; Phone: ____________________________ FAX: _______________________________
- +205 ;;
- +206 ;; NOTE: VA may request additional medical information, including additional
- +207 ;; examinations if necessary to complete VA's review of the Veteran's
- +208 ;; application.
- +209 ;;
- +210 ;;^END^
- +211 QUIT