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Routine: DVBCQEA2

DVBCQEA2.m

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  1. DVBCQEA2  ;;ALB-CIOFO/ECF - EATING DISORDERS QUESTIONNAIRE ; 5/10/2010
  1.  ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs
  1.  ;; (VA) for disability benefits.  VA will consider the information you
  1.  ;; provide on this questionnaire as part of their evaluation in processing
  1.  ;; the Veteran's claim.
  1.  ;;
  1.  ;; NOTE: If the Veteran experiences a mental health emergency during the
  1.  ;; interview, please terminate the interview and obtain help, using local
  1.  ;; resources as appropriate. You may also contact the VA Suicide Prevention
  1.  ;; Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the
  1.  ;; Veteran to emergency care.
  1.  ;;
  1.  ;; NOTE: In order to conduct an examination for eating disorders, the examiner
  1.  ;; must meet one of the following criteria: a board-certified or board-eligible
  1.  ;; psychiatrist; a licensed doctorate-level psychologist; a
  1.  ;; doctorate-level mental health provider under the close supervision of a
  1.  ;; board-certified or board-eligible psychiatrist or licensed doctorate-level
  1.  ;; psychologist; a psychiatry resident under close supervision of a board-
  1.  ;; certified or board-eligible psychiatrist or licensed doctorate-level
  1.  ;; psychologist; or a clinical or counseling psychologist completing a one-year
  1.  ;; internship or residency (for purposes of a doctorate-level degree) under
  1.  ;; close supervision of a board-certified or board-eligible psychiatrist or
  1.  ;; licensed doctorate-level psychologist.
  1.  ;;
  1.  ;; In order to conduct a REVIEW examination for eating disorders, the examiner
  1.  ;; must meet one of the criteria from above, OR be a licensed clinical social
  1.  ;; worker (LCSW), a nurse practitioner, a clinical nurse specialist, or a
  1.  ;; physician assistant, under close supervision of a board-certified or board-
  1.  ;; eligible psychiatrist or licensed doctorate-level psychologist.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;;
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with an eating
  1.  ;; disorder(s)?
  1.  ;;
  1.  ;; ___ Yes  ___ No
  1.  ;;
  1.  ;; If no, provide rationale (e.g., Veteran does not currently have any
  1.  ;; diagnosed eating disorders): _______________________________________________
  1.  ;;
  1.  ;; If yes, check all diagnoses that apply:
  1.  ;;
  1.  ;; ___ Bulimia
  1.  ;;
  1.  ;;     Date of diagnosis: ____________________
  1.  ;;
  1.  ;;     ICD code: __________
  1.  ;;
  1.  ;;     Name of diagnosing facility or clinician: ______________________________
  1.  ;;^TOF^
  1.  ;; ___ Anorexia
  1.  ;;
  1.  ;;     Date of diagnosis: ____________________
  1.  ;;
  1.  ;;     ICD code: __________
  1.  ;;
  1.  ;;     Name of diagnosing facility or clinician: ______________________________
  1.  ;
  1.  ;; ___ Eating disorder not otherwise specified
  1.  ;;
  1.  ;;     Date of diagnosis: ____________________
  1.  ;;
  1.  ;;     ICD code: __________
  1.  ;;
  1.  ;;     Name of diagnosing facility or clinician: ______________________________
  1.  ;;
  1.  ;; 2. Medical History
  1.  ;;
  1.  ;; Describe the history (including onset and course) of the Veteran's eating
  1.  ;; disorder (brief summary): 
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 3. Findings
  1.  ;;
  1.  ;; NOTE: For VA purposes, an incapacitating episode is defined as a period
  1.  ;; during which bedrest and treatment by a physician are required.
  1.  ;;
  1.  ;; ___ Binge eating followed by self-induced vomiting or other measures to
  1.  ;;     prevent weight gain, or resistance to weight gain even when below
  1.  ;;     expected minimum weight, with diagnosis of an eating disorder but
  1.  ;;     without incapacitating episodes
  1.  ;; ___ Binge eating followed by self-induced vomiting or other measures to
  1.  ;;     prevent weight gain, or resistance to weight gain even when below
  1.  ;;     expected minimum weight, with diagnosis of an eating disorder and
  1.  ;;     incapacitating episodes of up to two weeks total duration per year
  1.  ;; ___ Self-induced weight loss to less than 85 percent of expected minimum
  1.  ;;     weight with incapacitating episodes of more than two but less than
  1.  ;;     six weeks total duration per year
  1.  ;; ___ Self-induced weight loss to less than 85 percent of expected minimum
  1.  ;;     weight with incapacitating episodes of six or more weeks total duration
  1.  ;;     per year
  1.  ;; ___ Self-induced weight loss to less than 80 percent of expected minimum
  1.  ;;     weight, with incapacitating episodes of at least six weeks total
  1.  ;;     duration per year, and requiring hospitalization more than twice a year
  1.  ;;     for parenteral nutrition or tube feeding
  1.  ;;^TOF^
  1.  ;; 4. Other symptoms
  1.  ;;
  1.  ;; Does the Veteran have any other symptoms attributable to an eating disorder?
  1.  ;;
  1.  ;; ___ Yes ___ No
  1.  ;;
  1.  ;; If yes, describe: _________________________________________________________
  1.  ;;
  1.  ;; 5. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's eating disorder(s) impact his or her ability to work?
  1.  ;;
  1.  ;; ___ Yes  ___ No
  1.  ;;
  1.  ;; If yes, describe impact, providing one or more examples: ___________________
  1.  ;;
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 6. Remarks, if any _________________________________________________________
  1.  ;;
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; Psychiatrist/Psychologist/examiner signature & title: ______________________
  1.  ;;
  1.  ;; Psychiatrist/Psychologist/examiner printed name: ___________________________
  1.  ;;
  1.  ;; Date: ________________________   Phone: ____________________________________
  1.  ;;
  1.  ;; License #: _____________ 
  1.  ;;
  1.  ;; Psychiatrist/Psychologist/examiner address: ________________________________
  1.  ;;
  1.  ;; ____________________________________________________________________________
  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