- 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 Jan 18, 2025@02:47:17 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