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Routine: DVBCQMD2

DVBCQMD2.m

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  1. DVBCQMD2 ;;ALB-CIOFO/ECF - MENTAL DISORDERS QUESTIONNAIRE ; 9/20/2010
  1. ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
  1. ;
  1. TXT ;
  1. ;;
  1. ;; Your patient is applying to the U. S. Department of Veterans Affairs
  1. ;; (VA) for disability benefits. VA will consider the information you
  1. ;; provide on this questionnaire as part of their evaluation in processing
  1. ;; 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 VA Suicide Prevention
  1. ;; Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the
  1. ;; Veteran to emergency care.
  1. ;;
  1. ;; NOTE: In order to conduct an initial examination for mental 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-
  1. ;; year internship or residency (for purposes of a doctorate-level degree)
  1. ;; under close supervision of a board-certified or board-eligible
  1. ;; psychiatrist or licensed doctorate-level psychologist.
  1. ;;
  1. ;; In order to conduct a REVIEW examination for mental 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. ;; Does the Veteran now have or has he/she ever been diagnosed with a mental
  1. ;; disorder(s)?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; NOTE: If the Veteran has a diagnosis of an eating disorder, complete the
  1. ;; Eating Disorder Questionnaire in lieu of this Questionnaire.
  1. ;; NOTE: If the Veteran has a diagnosis of PTSD, the PTSD Questionnaire must
  1. ;; be completed by a VHA staff or contract examiner in lieu of this
  1. ;; Questionnaire.
  1. ;;
  1. ;; If no, provide rationale (e.g., Veteran does not currently have any
  1. ;; diagnosed mental disorders): _____________________________________________
  1. ;;^TOF^
  1. ;; If the Veteran has more than one mental health diagnosis, provide all
  1. ;; diagnoses:
  1. ;;
  1. ;; Diagnosis #1: ___________________________
  1. ;;
  1. ;; ICD code: __________
  1. ;;
  1. ;; Date of diagnosis: ______________________
  1. ;;
  1. ;; Name of diagnosing facility or clinician: __________________________________
  1. ;;
  1. ;; Diagnosis #2: ___________________________
  1. ;;
  1. ;; ICD code: __________
  1. ;;
  1. ;; Date of diagnosis: ______________________
  1. ;;
  1. ;; Name of diagnosing facility or clinician: __________________________________
  1. ;;
  1. ;; Diagnosis #3: _____________________________
  1. ;;
  1. ;; ICD code: __________
  1. ;;
  1. ;; Date of diagnosis: ______________________
  1. ;;
  1. ;; Name of diagnosing facility or clinician: __________________________________
  1. ;;
  1. ;; If additional diagnoses that pertain to mental health disorders, list using
  1. ;; above format: ______________________________________________________________
  1. ;;
  1. ;;^TOF^
  1. ;; 2. Medical History
  1. ;;
  1. ;; Describe the history (including onset and course) of the Veteran's mental
  1. ;; conditions (brief summary):
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; 3. Symptoms
  1. ;;
  1. ;; For each level below, check all symptoms that apply.
  1. ;;
  1. ;; Level I
  1. ;;
  1. ;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
  1. ;;
  1. ;; If yes, check all that apply:
  1. ;; ___ Depressed mood
  1. ;; ___ Anxiety
  1. ;; ___ Suspiciousness
  1. ;; ___ Panic attacks that occur weekly or less often
  1. ;; ___ Chronic sleep impairment
  1. ;; ___ Mild memory loss, such as forgetting names, directions or recent
  1. ;; events
  1. ;;^TOF^
  1. ;; Level II
  1. ;;
  1. ;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
  1. ;;
  1. ;; If yes, check all that apply:
  1. ;; ___ Flattened affect
  1. ;; ___ Circumstantial, circumlocutory or stereotyped speech
  1. ;; ___ Panic attacks more than once a week
  1. ;; ___ Difficulty in understanding complex commands
  1. ;; ___ Impairment of short- and long-term memory, for example, retention of
  1. ;; only highly learned material, while forgetting to complete tasks
  1. ;; ___ Impaired judgment
  1. ;; ___ Impaired abstract thinking
  1. ;; ___ Disturbances of motivation and mood
  1. ;; ___ Difficulty in establishing and maintaining effective work and social
  1. ;; relationships
  1. ;;
  1. ;; Level III
  1. ;;
  1. ;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
  1. ;;
  1. ;; If yes, check all that apply:
  1. ;; ___ Suicidal ideation
  1. ;; ___ Obsessional rituals which interfere with routine activities
  1. ;; ___ Speech intermittently illogical, obscure, or irrelevant
  1. ;; ___ Near-continuous panic or depression affecting the ability to function
  1. ;; independently, appropriately and effectively
  1. ;; ___ Impaired impulse control, such as unprovoked irritability with
  1. ;; periods of violence
  1. ;; ___ Spatial disorientation
  1. ;; ___ Neglect of personal appearance and hygiene
  1. ;; ___ Difficulty in adapting to stressful circumstances, including work or
  1. ;; a worklike setting
  1. ;; ___ Inability to establish and maintain effective relationships
  1. ;;^TOF^
  1. ;; Level IV
  1. ;;
  1. ;; Does the Veteran have any symptoms from the list below? ___ Yes ___ No
  1. ;;
  1. ;; If yes, check all that apply:
  1. ;; ___ Gross impairment in thought processes or communication
  1. ;; ___ Persistent delusions or hallucinations
  1. ;; ___ Grossly inappropriate behavior
  1. ;; ___ Persistent danger of hurting self or others
  1. ;; ___ Intermittent inability to perform activities of daily living,
  1. ;; including maintenance of minimal personal hygiene
  1. ;; ___ Disorientation to time or place
  1. ;; ___ Memory loss for names of close relatives, own occupation, or own name
  1. ;;
  1. ;; 4. Other symptoms
  1. ;;
  1. ;; Does the Veteran have any other symptoms attributable to mental disorders
  1. ;; that are not listed above?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, describe: ___________________________________________________
  1. ;;
  1. ;; 5. Differentiation of Symptoms
  1. ;;
  1. ;; Are you able to differentiate what portion of the symptom complex above is
  1. ;; caused by each diagnosis?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, list which symptoms are attributable to each diagnosis, where
  1. ;; possible: _______________________________________________________
  1. ;;^TOF^
  1. ;; 6. Occupational and social impairment
  1. ;;
  1. ;; Which of the following best represents the Veteran's level of occupational
  1. ;; and social impairment? (Check only one)
  1. ;;
  1. ;; ___ A mental condition has been formally diagnosed, but symptoms are not
  1. ;; severe enough either to interfere with occupational and social
  1. ;; functioning or to require continuous medication
  1. ;; ___ Occupational and social impairment due to mild or transient symptoms
  1. ;; which decrease work efficiency and ability to perform occupational tasks
  1. ;; only during periods of significant stress, or; symptoms controlled by
  1. ;; medication
  1. ;; ___ Occupational and social impairment with occasional decrease in work
  1. ;; efficiency and intermittent periods of inability to perform occupational
  1. ;; tasks, although generally functioning satisfactorily, with normal
  1. ;; routine behavior, self-care and conversation
  1. ;; ___ Occupational and social impairment with reduced reliability and
  1. ;; productivity
  1. ;; ___ Occupational and social impairment with deficiencies in most areas,
  1. ;; such as work, school, family relations, judgment, thinking and/or mood
  1. ;; ___ Total occupational and social impairment
  1. ;;
  1. ;; 7. Current global assessment of functioning (GAF) score: __________
  1. ;;
  1. ;; 8. Competency
  1. ;;
  1. ;; Is the Veteran capable of managing his or her financial affairs?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, explain: ____________________________________________________________
  1. ;;
  1. ;; 9. Diagnostic testing
  1. ;;
  1. ;; Has any mental health testing been performed?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, provide dates, types of testing and results: _______________________
  1. ;;
  1. ;; 10. Functional impact
  1. ;;
  1. ;; Does the Veteran's mental 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. ;;^TOF^
  1. ;; 11. Remarks, if any _______________________________________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; Psychiatrist/Psychologist/examiner signature & title: ______________________
  1. ;;
  1. ;; Psychiatrist/Psychologist/examiner printed name: ___________________________
  1. ;;
  1. ;; Date: ________________________ Phone: ____________________________________
  1. ;;
  1. ;; License #: _____________
  1. ;;
  1. ;; Psychiatrist/Psychologist/examiner 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