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Routine: DVBCQMD2

DVBCQMD2.m

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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