DVBCQEA2 ;;ALB-CIOFO/ECF - EATING DISORDERS QUESTIONNAIRE ; 5/10/2010
;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
;
TXT ;
;;
;; Your patient is applying to the U. S. Department of Veterans Affairs
;; (VA) for disability benefits. VA will consider the information you
;; provide on this questionnaire as part of their evaluation in processing
;; the Veteran's claim.
;;
;; NOTE: 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 VA Suicide Prevention
;; Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the
;; Veteran to emergency care.
;;
;; NOTE: In order to conduct an examination for eating disorders, the examiner
;; must meet one of the following criteria: a board-certified or board-eligible
;; psychiatrist; a licensed doctorate-level psychologist; a
;; doctorate-level mental health provider under the close supervision of a
;; board-certified or board-eligible psychiatrist or licensed doctorate-level
;; psychologist; a psychiatry resident under close supervision of a board-
;; certified or board-eligible psychiatrist or licensed doctorate-level
;; psychologist; or a clinical or counseling psychologist completing a one-year
;; internship or residency (for purposes of a doctorate-level degree) under
;; close supervision of a board-certified or board-eligible psychiatrist or
;; licensed doctorate-level psychologist.
;;
;; In order to conduct a REVIEW examination for eating disorders, the examiner
;; must meet one of the criteria from above, OR be a licensed clinical social
;; worker (LCSW), a nurse practitioner, a clinical nurse specialist, or a
;; physician assistant, under close supervision of a board-certified or board-
;; eligible psychiatrist or licensed doctorate-level psychologist.
;;
;; 1. Diagnosis
;;
;; Does the Veteran now have or has he/she ever been diagnosed with an eating
;; disorder(s)?
;;
;; ___ Yes ___ No
;;
;; If no, provide rationale (e.g., Veteran does not currently have any
;; diagnosed eating disorders): _______________________________________________
;;
;; If yes, check all diagnoses that apply:
;;
;; ___ Bulimia
;;
;; Date of diagnosis: ____________________
;;
;; ICD code: __________
;;
;; Name of diagnosing facility or clinician: ______________________________
;;^TOF^
;; ___ Anorexia
;;
;; Date of diagnosis: ____________________
;;
;; ICD code: __________
;;
;; Name of diagnosing facility or clinician: ______________________________
;
;; ___ Eating disorder not otherwise specified
;;
;; Date of diagnosis: ____________________
;;
;; ICD code: __________
;;
;; Name of diagnosing facility or clinician: ______________________________
;;
;; 2. Medical History
;;
;; Describe the history (including onset and course) of the Veteran's eating
;; disorder (brief summary):
;; _____________________________________________________________________________
;;
;; 3. Findings
;;
;; NOTE: For VA purposes, an incapacitating episode is defined as a period
;; during which bedrest and treatment by a physician are required.
;;
;; ___ Binge eating followed by self-induced vomiting or other measures to
;; prevent weight gain, or resistance to weight gain even when below
;; expected minimum weight, with diagnosis of an eating disorder but
;; without incapacitating episodes
;; ___ Binge eating followed by self-induced vomiting or other measures to
;; prevent weight gain, or resistance to weight gain even when below
;; expected minimum weight, with diagnosis of an eating disorder and
;; incapacitating episodes of up to two weeks total duration per year
;; ___ Self-induced weight loss to less than 85 percent of expected minimum
;; weight with incapacitating episodes of more than two but less than
;; six weeks total duration per year
;; ___ Self-induced weight loss to less than 85 percent of expected minimum
;; weight with incapacitating episodes of six or more weeks total duration
;; per year
;; ___ Self-induced weight loss to less than 80 percent of expected minimum
;; weight, with incapacitating episodes of at least six weeks total
;; duration per year, and requiring hospitalization more than twice a year
;; for parenteral nutrition or tube feeding
;;^TOF^
;; 4. Other symptoms
;;
;; Does the Veteran have any other symptoms attributable to an eating disorder?
;;
;; ___ Yes ___ No
;;
;; If yes, describe: _________________________________________________________
;;
;; 5. Functional impact
;;
;; Does the Veteran's eating disorder(s) impact his or her ability to work?
;;
;; ___ Yes ___ No
;;
;; If yes, describe impact, providing one or more examples: ___________________
;;
;; ____________________________________________________________________________
;;
;; 6. Remarks, if any _________________________________________________________
;;
;; ____________________________________________________________________________
;;
;; Psychiatrist/Psychologist/examiner signature & title: ______________________
;;
;; Psychiatrist/Psychologist/examiner printed name: ___________________________
;;
;; Date: ________________________ Phone: ____________________________________
;;
;; License #: _____________
;;
;; Psychiatrist/Psychologist/examiner address: ________________________________
;;
;; ____________________________________________________________________________
;;
;; 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[HDVBCQEA2 5944 printed Apr 09, 2024@20:55:21 Page 2
DVBCQEA2 ;;ALB-CIOFO/ECF - EATING DISORDERS QUESTIONNAIRE ; 5/10/2010
+1 ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;; NOTE: If the Veteran experiences a mental health emergency during the
+8 ;; interview, please terminate the interview and obtain help, using local
+9 ;; resources as appropriate. You may also contact the VA Suicide Prevention
+10 ;; Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the
+11 ;; Veteran to emergency care.
+12 ;;
+13 ;; NOTE: In order to conduct an examination for eating disorders, the examiner
+14 ;; must meet one of the following criteria: a board-certified or board-eligible
+15 ;; psychiatrist; a licensed doctorate-level psychologist; a
+16 ;; doctorate-level mental health provider under the close supervision of a
+17 ;; board-certified or board-eligible psychiatrist or licensed doctorate-level
+18 ;; psychologist; a psychiatry resident under close supervision of a board-
+19 ;; certified or board-eligible psychiatrist or licensed doctorate-level
+20 ;; psychologist; or a clinical or counseling psychologist completing a one-year
+21 ;; internship or residency (for purposes of a doctorate-level degree) under
+22 ;; close supervision of a board-certified or board-eligible psychiatrist or
+23 ;; licensed doctorate-level psychologist.
+24 ;;
+25 ;; In order to conduct a REVIEW examination for eating disorders, the examiner
+26 ;; must meet one of the criteria from above, OR be a licensed clinical social
+27 ;; worker (LCSW), a nurse practitioner, a clinical nurse specialist, or a
+28 ;; physician assistant, under close supervision of a board-certified or board-
+29 ;; eligible psychiatrist or licensed doctorate-level psychologist.
+30 ;;
+31 ;; 1. Diagnosis
+32 ;;
+33 ;; Does the Veteran now have or has he/she ever been diagnosed with an eating
+34 ;; disorder(s)?
+35 ;;
+36 ;; ___ Yes ___ No
+37 ;;
+38 ;; If no, provide rationale (e.g., Veteran does not currently have any
+39 ;; diagnosed eating disorders): _______________________________________________
+40 ;;
+41 ;; If yes, check all diagnoses that apply:
+42 ;;
+43 ;; ___ Bulimia
+44 ;;
+45 ;; Date of diagnosis: ____________________
+46 ;;
+47 ;; ICD code: __________
+48 ;;
+49 ;; Name of diagnosing facility or clinician: ______________________________
+50 ;;^TOF^
+51 ;; ___ Anorexia
+52 ;;
+53 ;; Date of diagnosis: ____________________
+54 ;;
+55 ;; ICD code: __________
+56 ;;
+57 ;; Name of diagnosing facility or clinician: ______________________________
+58 ;
+59 ;; ___ Eating disorder not otherwise specified
+60 ;;
+61 ;; Date of diagnosis: ____________________
+62 ;;
+63 ;; ICD code: __________
+64 ;;
+65 ;; Name of diagnosing facility or clinician: ______________________________
+66 ;;
+67 ;; 2. Medical History
+68 ;;
+69 ;; Describe the history (including onset and course) of the Veteran's eating
+70 ;; disorder (brief summary):
+71 ;; _____________________________________________________________________________
+72 ;;
+73 ;; 3. Findings
+74 ;;
+75 ;; NOTE: For VA purposes, an incapacitating episode is defined as a period
+76 ;; during which bedrest and treatment by a physician are required.
+77 ;;
+78 ;; ___ Binge eating followed by self-induced vomiting or other measures to
+79 ;; prevent weight gain, or resistance to weight gain even when below
+80 ;; expected minimum weight, with diagnosis of an eating disorder but
+81 ;; without incapacitating episodes
+82 ;; ___ Binge eating followed by self-induced vomiting or other measures to
+83 ;; prevent weight gain, or resistance to weight gain even when below
+84 ;; expected minimum weight, with diagnosis of an eating disorder and
+85 ;; incapacitating episodes of up to two weeks total duration per year
+86 ;; ___ Self-induced weight loss to less than 85 percent of expected minimum
+87 ;; weight with incapacitating episodes of more than two but less than
+88 ;; six weeks total duration per year
+89 ;; ___ Self-induced weight loss to less than 85 percent of expected minimum
+90 ;; weight with incapacitating episodes of six or more weeks total duration
+91 ;; per year
+92 ;; ___ Self-induced weight loss to less than 80 percent of expected minimum
+93 ;; weight, with incapacitating episodes of at least six weeks total
+94 ;; duration per year, and requiring hospitalization more than twice a year
+95 ;; for parenteral nutrition or tube feeding
+96 ;;^TOF^
+97 ;; 4. Other symptoms
+98 ;;
+99 ;; Does the Veteran have any other symptoms attributable to an eating disorder?
+100 ;;
+101 ;; ___ Yes ___ No
+102 ;;
+103 ;; If yes, describe: _________________________________________________________
+104 ;;
+105 ;; 5. Functional impact
+106 ;;
+107 ;; Does the Veteran's eating disorder(s) impact his or her ability to work?
+108 ;;
+109 ;; ___ Yes ___ No
+110 ;;
+111 ;; If yes, describe impact, providing one or more examples: ___________________
+112 ;;
+113 ;; ____________________________________________________________________________
+114 ;;
+115 ;; 6. Remarks, if any _________________________________________________________
+116 ;;
+117 ;; ____________________________________________________________________________
+118 ;;
+119 ;; Psychiatrist/Psychologist/examiner signature & title: ______________________
+120 ;;
+121 ;; Psychiatrist/Psychologist/examiner printed name: ___________________________
+122 ;;
+123 ;; Date: ________________________ Phone: ____________________________________
+124 ;;
+125 ;; License #: _____________
+126 ;;
+127 ;; Psychiatrist/Psychologist/examiner address: ________________________________
+128 ;;
+129 ;; ____________________________________________________________________________
+130 ;;
+131 ;; NOTE: VA may request additional medical information, including additional
+132 ;; examinations if necessary to complete VA's review of the Veteran's
+133 ;; application.
+134 ;;
+135 ;;^END^
+136 QUIT
