- 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 Jan 18, 2025@02:48:22 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