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Routine: DVBCQEA4

DVBCQEA4.m

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  1. DVBCQEA4 ;;ALB-CIOFO/SBW - EATING DISORDERS QUESTIONNAIRE (V2); 7/APR/2011
  1. ;;2.7;AMIE;**166**;Apr 10, 1995;Build 6
  1. ;
  1. TXT ;
  1. ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1. ;; disability benefits. VA will consider the information you provide on this
  1. ;; questionnaire as part of their evaluation in processing 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 Veterans Crisis Line at
  1. ;; 1-800-273-TALK (8255). Stay on the Crisis Line until help can link the
  1. ;; Veteran to emergency care.
  1. ;;
  1. ;; NOTE: In order to conduct an initial examination for eating disorders, the
  1. ;; examiner must meet one of the following criteria: a board-certified or
  1. ;; board-eligible 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 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 signature & title: _______________________________
  1. ;;
  1. ;; Psychiatrist/Psychologist printed name: ____________________________________
  1. ;;
  1. ;; Date: ________________________ Phone: ____________________________________
  1. ;;
  1. ;; License #: ___________________ Fax: ______________________________________
  1. ;;
  1. ;; Psychiatrist/Psychologist 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