DVBCQMD2 ;;ALB-CIOFO/ECF - MENTAL DISORDERS QUESTIONNAIRE ; 9/20/2010
;;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 initial examination for mental 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 mental 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 a mental
;; disorder(s)?
;;
;; ___ Yes ___ No
;;
;; NOTE: If the Veteran has a diagnosis of an eating disorder, complete the
;; Eating Disorder Questionnaire in lieu of this Questionnaire.
;; NOTE: If the Veteran has a diagnosis of PTSD, the PTSD Questionnaire must
;; be completed by a VHA staff or contract examiner in lieu of this
;; Questionnaire.
;;
;; If no, provide rationale (e.g., Veteran does not currently have any
;; diagnosed mental disorders): _____________________________________________
;;^TOF^
;; If the Veteran has more than one mental health diagnosis, provide all
;; diagnoses:
;;
;; Diagnosis #1: ___________________________
;;
;; ICD code: __________
;;
;; Date of diagnosis: ______________________
;;
;; Name of diagnosing facility or clinician: __________________________________
;;
;; Diagnosis #2: ___________________________
;;
;; ICD code: __________
;;
;; Date of diagnosis: ______________________
;;
;; Name of diagnosing facility or clinician: __________________________________
;;
;; Diagnosis #3: _____________________________
;;
;; ICD code: __________
;;
;; Date of diagnosis: ______________________
;;
;; Name of diagnosing facility or clinician: __________________________________
;;
;; If additional diagnoses that pertain to mental health disorders, list using
;; above format: ______________________________________________________________
;;
;;^TOF^
;; 2. Medical History
;;
;; Describe the history (including onset and course) of the Veteran's mental
;; conditions (brief summary):
;; ____________________________________________________________________________
;;
;; 3. Symptoms
;;
;; For each level below, check all symptoms that apply.
;;
;; Level I
;;
;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ___ Depressed mood
;; ___ Anxiety
;; ___ Suspiciousness
;; ___ Panic attacks that occur weekly or less often
;; ___ Chronic sleep impairment
;; ___ Mild memory loss, such as forgetting names, directions or recent
;; events
;;^TOF^
;; Level II
;;
;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ___ Flattened affect
;; ___ Circumstantial, circumlocutory or stereotyped speech
;; ___ Panic attacks more than once a week
;; ___ Difficulty in understanding complex commands
;; ___ Impairment of short- and long-term memory, for example, retention of
;; only highly learned material, while forgetting to complete tasks
;; ___ Impaired judgment
;; ___ Impaired abstract thinking
;; ___ Disturbances of motivation and mood
;; ___ Difficulty in establishing and maintaining effective work and social
;; relationships
;;
;; Level III
;;
;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ___ Suicidal ideation
;; ___ Obsessional rituals which interfere with routine activities
;; ___ Speech intermittently illogical, obscure, or irrelevant
;; ___ Near-continuous panic or depression affecting the ability to function
;; independently, appropriately and effectively
;; ___ Impaired impulse control, such as unprovoked irritability with
;; periods of violence
;; ___ Spatial disorientation
;; ___ Neglect of personal appearance and hygiene
;; ___ Difficulty in adapting to stressful circumstances, including work or
;; a worklike setting
;; ___ Inability to establish and maintain effective relationships
;;^TOF^
;; Level IV
;;
;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ___ Gross impairment in thought processes or communication
;; ___ Persistent delusions or hallucinations
;; ___ Grossly inappropriate behavior
;; ___ Persistent danger of hurting self or others
;; ___ Intermittent inability to perform activities of daily living,
;; including maintenance of minimal personal hygiene
;; ___ Disorientation to time or place
;; ___ Memory loss for names of close relatives, own occupation, or own name
;;
;; 4. Other symptoms
;;
;; Does the Veteran have any other symptoms attributable to mental disorders
;; that are not listed above?
;; ___ Yes ___ No
;;
;; If yes, describe: ___________________________________________________
;;
;; 5. Differentiation of Symptoms
;;
;; Are you able to differentiate what portion of the symptom complex above is
;; caused by each diagnosis?
;; ___ Yes ___ No
;;
;; If yes, list which symptoms are attributable to each diagnosis, where
;; possible: _______________________________________________________
;;^TOF^
;; 6. Occupational and social impairment
;;
;; Which of the following best represents the Veteran's level of occupational
;; and social impairment? (Check only one)
;;
;; ___ A mental condition has been formally diagnosed, but symptoms are not
;; severe enough either to interfere with occupational and social
;; functioning or to require continuous medication
;; ___ Occupational and social impairment due to mild or transient symptoms
;; which decrease work efficiency and ability to perform occupational tasks
;; only during periods of significant stress, or; symptoms controlled by
;; medication
;; ___ Occupational and social impairment with occasional decrease in work
;; efficiency and intermittent periods of inability to perform occupational
;; tasks, although generally functioning satisfactorily, with normal
;; routine behavior, self-care and conversation
;; ___ Occupational and social impairment with reduced reliability and
;; productivity
;; ___ Occupational and social impairment with deficiencies in most areas,
;; such as work, school, family relations, judgment, thinking and/or mood
;; ___ Total occupational and social impairment
;;
;; 7. Current global assessment of functioning (GAF) score: __________
;;
;; 8. Competency
;;
;; Is the Veteran capable of managing his or her financial affairs?
;;
;; ___ Yes ___ No
;;
;; If no, explain: ____________________________________________________________
;;
;; 9. Diagnostic testing
;;
;; Has any mental health testing been performed?
;; ___ Yes ___ No
;;
;; If yes, provide dates, types of testing and results: _______________________
;;
;; 10. Functional impact
;;
;; Does the Veteran's mental disorder(s) impact his or her ability to work?
;;
;; ___ Yes ___ No
;;
;; If yes, describe impact, providing one or more examples: ___________________
;;
;; ___________________________________________________________________________
;;^TOF^
;; 11. 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[HDVBCQMD2 9920 printed Apr 09, 2024@20:58:55 Page 2
DVBCQMD2 ;;ALB-CIOFO/ECF - MENTAL DISORDERS QUESTIONNAIRE ; 9/20/2010
+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 initial examination for mental disorders, the
+14 ;; examiner must meet one of the following criteria: a board-certified or
+15 ;; board-eligible 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-
+21 ;; year internship or residency (for purposes of a doctorate-level degree)
+22 ;; under close supervision of a board-certified or board-eligible
+23 ;; psychiatrist or licensed doctorate-level psychologist.
+24 ;;
+25 ;; In order to conduct a REVIEW examination for mental 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 ;; Does the Veteran now have or has he/she ever been diagnosed with a mental
+33 ;; disorder(s)?
+34 ;;
+35 ;; ___ Yes ___ No
+36 ;;
+37 ;; NOTE: If the Veteran has a diagnosis of an eating disorder, complete the
+38 ;; Eating Disorder Questionnaire in lieu of this Questionnaire.
+39 ;; NOTE: If the Veteran has a diagnosis of PTSD, the PTSD Questionnaire must
+40 ;; be completed by a VHA staff or contract examiner in lieu of this
+41 ;; Questionnaire.
+42 ;;
+43 ;; If no, provide rationale (e.g., Veteran does not currently have any
+44 ;; diagnosed mental disorders): _____________________________________________
+45 ;;^TOF^
+46 ;; If the Veteran has more than one mental health diagnosis, provide all
+47 ;; diagnoses:
+48 ;;
+49 ;; Diagnosis #1: ___________________________
+50 ;;
+51 ;; ICD code: __________
+52 ;;
+53 ;; Date of diagnosis: ______________________
+54 ;;
+55 ;; Name of diagnosing facility or clinician: __________________________________
+56 ;;
+57 ;; Diagnosis #2: ___________________________
+58 ;;
+59 ;; ICD code: __________
+60 ;;
+61 ;; Date of diagnosis: ______________________
+62 ;;
+63 ;; Name of diagnosing facility or clinician: __________________________________
+64 ;;
+65 ;; Diagnosis #3: _____________________________
+66 ;;
+67 ;; ICD code: __________
+68 ;;
+69 ;; Date of diagnosis: ______________________
+70 ;;
+71 ;; Name of diagnosing facility or clinician: __________________________________
+72 ;;
+73 ;; If additional diagnoses that pertain to mental health disorders, list using
+74 ;; above format: ______________________________________________________________
+75 ;;
+76 ;;^TOF^
+77 ;; 2. Medical History
+78 ;;
+79 ;; Describe the history (including onset and course) of the Veteran's mental
+80 ;; conditions (brief summary):
+81 ;; ____________________________________________________________________________
+82 ;;
+83 ;; 3. Symptoms
+84 ;;
+85 ;; For each level below, check all symptoms that apply.
+86 ;;
+87 ;; Level I
+88 ;;
+89 ;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
+90 ;;
+91 ;; If yes, check all that apply:
+92 ;; ___ Depressed mood
+93 ;; ___ Anxiety
+94 ;; ___ Suspiciousness
+95 ;; ___ Panic attacks that occur weekly or less often
+96 ;; ___ Chronic sleep impairment
+97 ;; ___ Mild memory loss, such as forgetting names, directions or recent
+98 ;; events
+99 ;;^TOF^
+100 ;; Level II
+101 ;;
+102 ;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
+103 ;;
+104 ;; If yes, check all that apply:
+105 ;; ___ Flattened affect
+106 ;; ___ Circumstantial, circumlocutory or stereotyped speech
+107 ;; ___ Panic attacks more than once a week
+108 ;; ___ Difficulty in understanding complex commands
+109 ;; ___ Impairment of short- and long-term memory, for example, retention of
+110 ;; only highly learned material, while forgetting to complete tasks
+111 ;; ___ Impaired judgment
+112 ;; ___ Impaired abstract thinking
+113 ;; ___ Disturbances of motivation and mood
+114 ;; ___ Difficulty in establishing and maintaining effective work and social
+115 ;; relationships
+116 ;;
+117 ;; Level III
+118 ;;
+119 ;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
+120 ;;
+121 ;; If yes, check all that apply:
+122 ;; ___ Suicidal ideation
+123 ;; ___ Obsessional rituals which interfere with routine activities
+124 ;; ___ Speech intermittently illogical, obscure, or irrelevant
+125 ;; ___ Near-continuous panic or depression affecting the ability to function
+126 ;; independently, appropriately and effectively
+127 ;; ___ Impaired impulse control, such as unprovoked irritability with
+128 ;; periods of violence
+129 ;; ___ Spatial disorientation
+130 ;; ___ Neglect of personal appearance and hygiene
+131 ;; ___ Difficulty in adapting to stressful circumstances, including work or
+132 ;; a worklike setting
+133 ;; ___ Inability to establish and maintain effective relationships
+134 ;;^TOF^
+135 ;; Level IV
+136 ;;
+137 ;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
+138 ;;
+139 ;; If yes, check all that apply:
+140 ;; ___ Gross impairment in thought processes or communication
+141 ;; ___ Persistent delusions or hallucinations
+142 ;; ___ Grossly inappropriate behavior
+143 ;; ___ Persistent danger of hurting self or others
+144 ;; ___ Intermittent inability to perform activities of daily living,
+145 ;; including maintenance of minimal personal hygiene
+146 ;; ___ Disorientation to time or place
+147 ;; ___ Memory loss for names of close relatives, own occupation, or own name
+148 ;;
+149 ;; 4. Other symptoms
+150 ;;
+151 ;; Does the Veteran have any other symptoms attributable to mental disorders
+152 ;; that are not listed above?
+153 ;; ___ Yes ___ No
+154 ;;
+155 ;; If yes, describe: ___________________________________________________
+156 ;;
+157 ;; 5. Differentiation of Symptoms
+158 ;;
+159 ;; Are you able to differentiate what portion of the symptom complex above is
+160 ;; caused by each diagnosis?
+161 ;; ___ Yes ___ No
+162 ;;
+163 ;; If yes, list which symptoms are attributable to each diagnosis, where
+164 ;; possible: _______________________________________________________
+165 ;;^TOF^
+166 ;; 6. Occupational and social impairment
+167 ;;
+168 ;; Which of the following best represents the Veteran's level of occupational
+169 ;; and social impairment? (Check only one)
+170 ;;
+171 ;; ___ A mental condition has been formally diagnosed, but symptoms are not
+172 ;; severe enough either to interfere with occupational and social
+173 ;; functioning or to require continuous medication
+174 ;; ___ Occupational and social impairment due to mild or transient symptoms
+175 ;; which decrease work efficiency and ability to perform occupational tasks
+176 ;; only during periods of significant stress, or; symptoms controlled by
+177 ;; medication
+178 ;; ___ Occupational and social impairment with occasional decrease in work
+179 ;; efficiency and intermittent periods of inability to perform occupational
+180 ;; tasks, although generally functioning satisfactorily, with normal
+181 ;; routine behavior, self-care and conversation
+182 ;; ___ Occupational and social impairment with reduced reliability and
+183 ;; productivity
+184 ;; ___ Occupational and social impairment with deficiencies in most areas,
+185 ;; such as work, school, family relations, judgment, thinking and/or mood
+186 ;; ___ Total occupational and social impairment
+187 ;;
+188 ;; 7. Current global assessment of functioning (GAF) score: __________
+189 ;;
+190 ;; 8. Competency
+191 ;;
+192 ;; Is the Veteran capable of managing his or her financial affairs?
+193 ;;
+194 ;; ___ Yes ___ No
+195 ;;
+196 ;; If no, explain: ____________________________________________________________
+197 ;;
+198 ;; 9. Diagnostic testing
+199 ;;
+200 ;; Has any mental health testing been performed?
+201 ;; ___ Yes ___ No
+202 ;;
+203 ;; If yes, provide dates, types of testing and results: _______________________
+204 ;;
+205 ;; 10. Functional impact
+206 ;;
+207 ;; Does the Veteran's mental disorder(s) impact his or her ability to work?
+208 ;;
+209 ;; ___ Yes ___ No
+210 ;;
+211 ;; If yes, describe impact, providing one or more examples: ___________________
+212 ;;
+213 ;; ___________________________________________________________________________
+214 ;;^TOF^
+215 ;; 11. Remarks, if any _______________________________________________________
+216 ;;
+217 ;; ____________________________________________________________________________
+218 ;;
+219 ;; Psychiatrist/Psychologist/examiner signature & title: ______________________
+220 ;;
+221 ;; Psychiatrist/Psychologist/examiner printed name: ___________________________
+222 ;;
+223 ;; Date: ________________________ Phone: ____________________________________
+224 ;;
+225 ;; License #: _____________
+226 ;;
+227 ;; Psychiatrist/Psychologist/examiner address: ________________________________
+228 ;;
+229 ;; ____________________________________________________________________________
+230 ;;
+231 ;; NOTE: VA may request additional medical information, including additional
+232 ;; examinations if necessary to complete VA's review of the Veteran's
+233 ;; application.
+234 ;;
+235 ;;^END^
+236 QUIT
