DVBCQEA4 ;;ALB-CIOFO/SBW - EATING DISORDERS QUESTIONNAIRE (V2); 7/APR/2011
;;2.7;AMIE;**166**;Apr 10, 1995;Build 6
;
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 Veterans Crisis Line at
;; 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the
;; Veteran to emergency care.
;;
;; NOTE: In order to conduct an initial 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 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 signature & title: _______________________________
;;
;; Psychiatrist/Psychologist printed name: ____________________________________
;;
;; Date: ________________________ Phone: ____________________________________
;;
;; License #: ___________________ Fax: ______________________________________
;;
;; Psychiatrist/Psychologist 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[HDVBCQEA4 5842 printed Sep 15, 2024@21:10:19 Page 2
DVBCQEA4 ;;ALB-CIOFO/SBW - EATING DISORDERS QUESTIONNAIRE (V2); 7/APR/2011
+1 ;;2.7;AMIE;**166**;Apr 10, 1995;Build 6
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;;
+5 ;; NOTE: If the Veteran experiences a mental health emergency during the
+6 ;; interview, please terminate the interview and obtain help, using local
+7 ;; resources as appropriate. You may also contact the Veterans Crisis Line at
+8 ;; 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the
+9 ;; Veteran to emergency care.
+10 ;;
+11 ;; NOTE: In order to conduct an initial examination for eating disorders, the
+12 ;; examiner must meet one of the following criteria: a board-certified or
+13 ;; board-eligible psychiatrist; a licensed doctorate-level psychologist; a
+14 ;; doctorate-level mental health provider under the close supervision of a
+15 ;; board-certified or board-eligible psychiatrist or licensed doctorate-level
+16 ;; psychologist; a psychiatry resident under close supervision of a board-
+17 ;; certified or board-eligible psychiatrist or licensed doctorate-level
+18 ;; psychologist; or a clinical or counseling psychologist completing a one-year
+19 ;; internship or residency (for purposes of a doctorate-level degree) under
+20 ;; close supervision of a board-certified or board-eligible psychiatrist or
+21 ;; licensed doctorate-level psychologist.
+22 ;;
+23 ;; In order to conduct a REVIEW examination for eating disorders, the examiner
+24 ;; must meet one of the criteria from above, OR be a licensed clinical social
+25 ;; worker (LCSW), a nurse practitioner, a clinical nurse specialist, or a
+26 ;; physician assistant, under close supervision of a board-certified or board-
+27 ;; eligible psychiatrist or licensed doctorate-level psychologist.
+28 ;;
+29 ;; 1. Diagnosis
+30 ;;
+31 ;; Does the Veteran now have or has he/she ever been diagnosed with an eating
+32 ;; disorder(s)?
+33 ;;
+34 ;; ___ Yes ___ No
+35 ;;
+36 ;; If yes, check all diagnoses that apply:
+37 ;;
+38 ;; ___ Bulimia
+39 ;;
+40 ;; Date of diagnosis: ____________________
+41 ;;
+42 ;; ICD code: __________
+43 ;;
+44 ;; Name of diagnosing facility or clinician: ______________________________
+45 ;;^TOF^
+46 ;; ___ Anorexia
+47 ;;
+48 ;; Date of diagnosis: ____________________
+49 ;;
+50 ;; ICD code: __________
+51 ;;
+52 ;; Name of diagnosing facility or clinician: ______________________________
+53 ;;
+54 ;; ___ Eating disorder not otherwise specified
+55 ;;
+56 ;; Date of diagnosis: ____________________
+57 ;;
+58 ;; ICD code: __________
+59 ;;
+60 ;; Name of diagnosing facility or clinician: ______________________________
+61 ;;
+62 ;; 2. Medical history
+63 ;;
+64 ;; Describe the history (including onset and course) of the Veteran's eating
+65 ;; disorder (brief summary):
+66 ;; _____________________________________________________________________________
+67 ;;
+68 ;; 3. Findings
+69 ;;
+70 ;; NOTE: For VA purposes, an incapacitating episode is defined as a period
+71 ;; during which bedrest and treatment by a physician are required.
+72 ;;
+73 ;; ___ Binge eating followed by self-induced vomiting or other measures to
+74 ;; prevent weight gain, or resistance to weight gain even when below
+75 ;; expected minimum weight, with diagnosis of an eating disorder but
+76 ;; without incapacitating episodes
+77 ;; ___ Binge eating followed by self-induced vomiting or other measures to
+78 ;; prevent weight gain, or resistance to weight gain even when below
+79 ;; expected minimum weight, with diagnosis of an eating disorder and
+80 ;; incapacitating episodes of up to two weeks total duration per year
+81 ;; ___ Self-induced weight loss to less than 85 percent of expected minimum
+82 ;; weight with incapacitating episodes of more than two but less than
+83 ;; six weeks total duration per year
+84 ;; ___ Self-induced weight loss to less than 85 percent of expected minimum
+85 ;; weight with incapacitating episodes of six or more weeks total duration
+86 ;; per year
+87 ;; ___ Self-induced weight loss to less than 80 percent of expected minimum
+88 ;; weight, with incapacitating episodes of at least six weeks total
+89 ;; duration per year, and requiring hospitalization more than twice a year
+90 ;; for parenteral nutrition or tube feeding
+91 ;;^TOF^
+92 ;; 4. Other symptoms
+93 ;;
+94 ;; Does the Veteran have any other symptoms attributable to an eating disorder?
+95 ;;
+96 ;; ___ Yes ___ No
+97 ;;
+98 ;; If yes, describe: _________________________________________________________
+99 ;;
+100 ;; 5. Functional impact
+101 ;;
+102 ;; Does the Veteran's eating disorder(s) impact his or her ability to work?
+103 ;;
+104 ;; ___ Yes ___ No
+105 ;;
+106 ;; If yes, describe impact, providing one or more examples: ___________________
+107 ;;
+108 ;; ____________________________________________________________________________
+109 ;;
+110 ;; 6. Remarks, if any _________________________________________________________
+111 ;;
+112 ;; ____________________________________________________________________________
+113 ;;
+114 ;; Psychiatrist/Psychologist signature & title: _______________________________
+115 ;;
+116 ;; Psychiatrist/Psychologist printed name: ____________________________________
+117 ;;
+118 ;; Date: ________________________ Phone: ____________________________________
+119 ;;
+120 ;; License #: ___________________ Fax: ______________________________________
+121 ;;
+122 ;; Psychiatrist/Psychologist address: _________________________________________
+123 ;;
+124 ;; ____________________________________________________________________________
+125 ;;
+126 ;; NOTE: VA may request additional medical information, including additional
+127 ;; examinations if necessary to complete VA's review of the Veteran's
+128 ;; application.
+129 ;;
+130 ;;^END^
+131 QUIT
