DVBCQMD4 ;;ALB-CIOFO/ECF,SBW - MENTAL DISORDERS QUESTIONNAIRE (v2) ; 15/JUNE/2011
;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
;
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.
;; Please note that this questionnaire is for disability evaluation, not for
;; treatment purposes.
;;
;; 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 Veterans Crisis Line at
;; 1-800-273-TALK (8255). Stay on the Crisis Line 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.
;;
;; This Questionnaire is to be completed for both initial and review mental
;; disorder(s) claims.
;;
;; SECTION I:
;; ----------
;;
;; 1. Diagnosis
;; a. 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 Disorders Questionnaire in lieu of this Questionnaire.
;; NOTE: If the Veteran has a diagnosis of PTSD, the Initial PTSD Questionnaire
;; must be completed by a VHA staff or contract examiner in lieu of this
;; Questionnaire.
;;^TOF^
;; If the Veteran currently has one or more mental disorders that conform to
;; DSM-IV criteria, provide all diagnoses:
;; Diagnosis #1: ______________________
;; ICD code: __________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II
;; Comments, if any: ___________________________________________________________
;;
;; Diagnosis #2: ______________________
;; ICD code: __________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II
;; Comments, if any: ___________________________________________________________
;;
;; Diagnosis #3: ______________________
;; ICD code: __________
;; Indicate the Axis category:
;; ___ Axis I ___ Axis II
;; Comments, if any: ___________________________________________________________
;;
;; If additional diagnoses that pertain to mental health disorders, list using
;; above format: _______________________________________________________________
;;
;; b. Axis III - medical diagnoses (to include TBI):
;; ICD code: __________
;; Comments, if any: ___________________________________________________________
;;
;; c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
;; _____________________________________________________________________________
;;
;; d. Axis V - Current global assessment of functioning (GAF) score: ___________
;; Comments, if any: ___________________________________________________________
;;
;; 2. Differentiation of symptoms
;; a. Does the Veteran have more than one mental disorder diagnosed?
;; ___ Yes ___ No
;; If yes, complete the following question:
;;
;; b. Is it possible to differentiate what symptom(s) is/are attributable to
;; each diagnosis?
;; ___ Yes ___ No ___ Not applicable (N/A)
;; If no, provide reason that it is not possible to differentiate what portion
;; of each symptom is attributable to each diagnosis: __________________________
;; _____________________________________________________________________________
;; If yes, list which symptoms are attributable to each diagnosis: _____________
;; _____________________________________________________________________________
;;^TOF^
;; c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
;; ___ Yes ___ No ___ Not shown in records reviewed Comments, if any:
;; _____________________________________________________________________________
;; If yes, complete the following question:
;;
;; d. Is it possible to differentiate what symptom(s) is/are attributable to
;; each diagnosis?
;; ___ Yes ___ No ___ Not applicable (N/A)
;; If no, provide reason that it is not possible to differentiate what portion
;; of each symptom is attributable to each diagnosis: __________________________
;; _____________________________________________________________________________
;; If yes, list which symptoms are attributable to each diagnosis: _____________
;; _____________________________________________________________________________
;;
;; 3. Occupational and social impairment
;; a. Which of the following best summarizes the Veteran's level of occupational
;; and social impairment with regards to all mental diagnoses?
;; (Check only one)
;; ___ No mental disorder diagnosis
;; ___ 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
;;
;; b. For the indicated level of occupational and social impairment, is it
;; possible to differentiate what portion of the occupational and social
;; impairment indicated above is caused by each mental disorder?
;; ___ Yes ___ No ___ No other mental disorder has been diagnosed
;; If no, provide reason that it is not possible to differentiate what portion
;; of the indicated level of occupational and social impairment is attributable
;; to each diagnosis: __________________________________________________________
;; If yes, list which portion of the indicated level of occupational and social
;; impairment is attributable to each diagnosis: _______________________________
;;^TOF^
;; c. If a diagnosis of TBI exists, is it possible to differentiate what portion
;; of the occupational and social impairment indicated above is caused by the TBI?
;; ___ Yes ___ No ___ No diagnosis of TBI
;; If no, provide reason that it is not possible to differentiate what portion
;; of the indicated level of occupational and social impairment is attributable
;; to each diagnosis: __________________________________________________________
;; If yes, list which portion of the indicated level of occupational and social
;; impairment is attributable to each diagnosis: _______________________________
;;
;; SECTION II:
;; -----------
;; Clinical Findings:
;; ------------------
;;
;; 1. Evidence review
;; If any records (evidence) were reviewed, please list here: __________________
;; _____________________________________________________________________________
;;
;; 2. History
;; NOTE: Initial examinations require pre-military, military, and post-military
;; history. If this is a review examination only indicate any relevant history
;; since prior exam.
;;
;; a. Relevant Social/Marital/Family history (pre-military, military, and post-
;; military): __________________________________________________________________
;;
;; b. Relevant Occupational and Educational history (pre-military, military, and
;; post-military): _____________________________________________________________
;;
;; c. Relevant Mental Health history, to include prescribed medications and
;; family mental health (pre-military, military, and post-military): ___________
;; _____________________________________________________________________________
;;
;; d. Relevant Legal and Behavioral history (pre-military, military, and post-
;; military): __________________________________________________________________
;;
;; e. Relevant Substance abuse history (pre-military, military, and post-
;; military): __________________________________________________________________
;;
;; f. Sentinel Event(s) (other than stressors): ________________________________
;; _____________________________________________________________________________
;;
;; g. Other, if any: ___________________________________________________________
;;^TOF^
;; 3. Symptoms
;; For VA rating purposes, check all symptoms that apply to the Veteran's
;; diagnoses:
;; ___ Depressed mood
;; ___ Anxiety
;; ___ Suspiciousness
;; ___ Panic attacks that occur weekly or less often
;; ___ Panic attacks more than once a week
;; ___ Near-continuous panic or depression affecting the ability to function
;; independently, appropriately and effectively
;; ___ Chronic sleep impairment
;; ___ Mild memory loss, such as forgetting names, directions or recent events
;; ___ Impairment of short- and long-term memory, for example, retention of
;; only highly learned material, while forgetting to complete tasks
;; ___ Memory loss for names of close relatives, own occupation, or own name
;; ___ Flattened affect
;; ___ Circumstantial, circumlocutory or stereotyped speech
;; ___ Speech intermittently illogical, obscure, or irrelevant
;; ___ Difficulty in understanding complex commands
;; ___ Impaired judgment
;; ___ Impaired abstract thinking
;; ___ Gross impairment in thought processes or communication
;; ___ Disturbances of motivation and mood
;; ___ Difficulty in establishing and maintaining effective work and social
;; relationships
;; ___ Difficulty in adapting to stressful circumstances, including work or a
;; worklike setting
;; ___ Inability to establish and maintain effective relationships
;; ___ Suicidal ideation
;; ___ Obsessional rituals which interfere with routine activities
;; ___ Impaired impulse control, such as unprovoked irritability with periods
;; of violence
;; ___ Spatial disorientation
;; ___ Persistent delusions or hallucinations
;; ___ Grossly inappropriate behavior
;; ___ Persistent danger of hurting self or others
;; ___ Neglect of personal appearance and hygiene
;; ___ Intermittent inability to perform activities of daily living,
;; including maintenance of minimal personal hygiene
;; ___ Disorientation to time or place
;;^TOF^
;; 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. Competency
;; Is the Veteran capable of managing his or her financial affairs?
;; ___ Yes ___ No
;; If no, explain: _____________________________________________________________
;;
;; 6. Remarks, if any: _________________________________________________________
;;
;; Psychiatrist/Psychologist signature & title: _______________________________
;;
;; Psychiatrist/Psychologist printed name: ____________________________________
;;
;; Date: ________________________ Phone: ____________________________________
;;
;; License #: ___________________ Fax: ______________________________________
;;
;; Psychiatrist/Psychologist 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[HDVBCQMD4 13525 printed Apr 09, 2024@20:49:29 Page 2
DVBCQMD4 ;;ALB-CIOFO/ECF,SBW - MENTAL DISORDERS QUESTIONNAIRE (v2) ; 15/JUNE/2011
+1 ;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;; Please note that this questionnaire is for disability evaluation, not for
+5 ;; treatment purposes.
+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 Veterans Crisis Line at
+10 ;; 1-800-273-TALK (8255). Stay on the Crisis Line 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 ;; This Questionnaire is to be completed for both initial and review mental
+32 ;; disorder(s) claims.
+33 ;;
+34 ;; SECTION I:
+35 ;; ----------
+36 ;;
+37 ;; 1. Diagnosis
+38 ;; a. Does the Veteran now have or has he/she ever been diagnosed with a mental
+39 ;; disorder(s)?
+40 ;; ___ Yes ___ No
+41 ;;
+42 ;; NOTE: If the Veteran has a diagnosis of an eating disorder, complete the
+43 ;; Eating Disorders Questionnaire in lieu of this Questionnaire.
+44 ;; NOTE: If the Veteran has a diagnosis of PTSD, the Initial PTSD Questionnaire
+45 ;; must be completed by a VHA staff or contract examiner in lieu of this
+46 ;; Questionnaire.
+47 ;;^TOF^
+48 ;; If the Veteran currently has one or more mental disorders that conform to
+49 ;; DSM-IV criteria, provide all diagnoses:
+50 ;; Diagnosis #1: ______________________
+51 ;; ICD code: __________
+52 ;; Indicate the Axis category:
+53 ;; ___ Axis I ___ Axis II
+54 ;; Comments, if any: ___________________________________________________________
+55 ;;
+56 ;; Diagnosis #2: ______________________
+57 ;; ICD code: __________
+58 ;; Indicate the Axis category:
+59 ;; ___ Axis I ___ Axis II
+60 ;; Comments, if any: ___________________________________________________________
+61 ;;
+62 ;; Diagnosis #3: ______________________
+63 ;; ICD code: __________
+64 ;; Indicate the Axis category:
+65 ;; ___ Axis I ___ Axis II
+66 ;; Comments, if any: ___________________________________________________________
+67 ;;
+68 ;; If additional diagnoses that pertain to mental health disorders, list using
+69 ;; above format: _______________________________________________________________
+70 ;;
+71 ;; b. Axis III - medical diagnoses (to include TBI):
+72 ;; ICD code: __________
+73 ;; Comments, if any: ___________________________________________________________
+74 ;;
+75 ;; c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
+76 ;; _____________________________________________________________________________
+77 ;;
+78 ;; d. Axis V - Current global assessment of functioning (GAF) score: ___________
+79 ;; Comments, if any: ___________________________________________________________
+80 ;;
+81 ;; 2. Differentiation of symptoms
+82 ;; a. Does the Veteran have more than one mental disorder diagnosed?
+83 ;; ___ Yes ___ No
+84 ;; If yes, complete the following question:
+85 ;;
+86 ;; b. Is it possible to differentiate what symptom(s) is/are attributable to
+87 ;; each diagnosis?
+88 ;; ___ Yes ___ No ___ Not applicable (N/A)
+89 ;; If no, provide reason that it is not possible to differentiate what portion
+90 ;; of each symptom is attributable to each diagnosis: __________________________
+91 ;; _____________________________________________________________________________
+92 ;; If yes, list which symptoms are attributable to each diagnosis: _____________
+93 ;; _____________________________________________________________________________
+94 ;;^TOF^
+95 ;; c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
+96 ;; ___ Yes ___ No ___ Not shown in records reviewed Comments, if any:
+97 ;; _____________________________________________________________________________
+98 ;; If yes, complete the following question:
+99 ;;
+100 ;; d. Is it possible to differentiate what symptom(s) is/are attributable to
+101 ;; each diagnosis?
+102 ;; ___ Yes ___ No ___ Not applicable (N/A)
+103 ;; If no, provide reason that it is not possible to differentiate what portion
+104 ;; of each symptom is attributable to each diagnosis: __________________________
+105 ;; _____________________________________________________________________________
+106 ;; If yes, list which symptoms are attributable to each diagnosis: _____________
+107 ;; _____________________________________________________________________________
+108 ;;
+109 ;; 3. Occupational and social impairment
+110 ;; a. Which of the following best summarizes the Veteran's level of occupational
+111 ;; and social impairment with regards to all mental diagnoses?
+112 ;; (Check only one)
+113 ;; ___ No mental disorder diagnosis
+114 ;; ___ A mental condition has been formally diagnosed, but symptoms are not
+115 ;; severe enough either to interfere with occupational and social functioning
+116 ;; or to require continuous medication
+117 ;; ___ Occupational and social impairment due to mild or transient symptoms which
+118 ;; decrease work efficiency and ability to perform occupational tasks only
+119 ;; during periods of significant stress, or; symptoms controlled by medication
+120 ;; ___ Occupational and social impairment with occasional decrease in work
+121 ;; efficiency and intermittent periods of inability to perform occupational
+122 ;; tasks, although generally functioning satisfactorily, with normal routine
+123 ;; behavior, self-care and conversation
+124 ;; ___ Occupational and social impairment with reduced reliability and
+125 ;; productivity
+126 ;; ___ Occupational and social impairment with deficiencies in most areas, such
+127 ;; as work, school, family relations, judgment, thinking and/or mood
+128 ;; ___ Total occupational and social impairment
+129 ;;
+130 ;; b. For the indicated level of occupational and social impairment, is it
+131 ;; possible to differentiate what portion of the occupational and social
+132 ;; impairment indicated above is caused by each mental disorder?
+133 ;; ___ Yes ___ No ___ No other mental disorder has been diagnosed
+134 ;; If no, provide reason that it is not possible to differentiate what portion
+135 ;; of the indicated level of occupational and social impairment is attributable
+136 ;; to each diagnosis: __________________________________________________________
+137 ;; If yes, list which portion of the indicated level of occupational and social
+138 ;; impairment is attributable to each diagnosis: _______________________________
+139 ;;^TOF^
+140 ;; c. If a diagnosis of TBI exists, is it possible to differentiate what portion
+141 ;; of the occupational and social impairment indicated above is caused by the TBI?
+142 ;; ___ Yes ___ No ___ No diagnosis of TBI
+143 ;; If no, provide reason that it is not possible to differentiate what portion
+144 ;; of the indicated level of occupational and social impairment is attributable
+145 ;; to each diagnosis: __________________________________________________________
+146 ;; If yes, list which portion of the indicated level of occupational and social
+147 ;; impairment is attributable to each diagnosis: _______________________________
+148 ;;
+149 ;; SECTION II:
+150 ;; -----------
+151 ;; Clinical Findings:
+152 ;; ------------------
+153 ;;
+154 ;; 1. Evidence review
+155 ;; If any records (evidence) were reviewed, please list here: __________________
+156 ;; _____________________________________________________________________________
+157 ;;
+158 ;; 2. History
+159 ;; NOTE: Initial examinations require pre-military, military, and post-military
+160 ;; history. If this is a review examination only indicate any relevant history
+161 ;; since prior exam.
+162 ;;
+163 ;; a. Relevant Social/Marital/Family history (pre-military, military, and post-
+164 ;; military): __________________________________________________________________
+165 ;;
+166 ;; b. Relevant Occupational and Educational history (pre-military, military, and
+167 ;; post-military): _____________________________________________________________
+168 ;;
+169 ;; c. Relevant Mental Health history, to include prescribed medications and
+170 ;; family mental health (pre-military, military, and post-military): ___________
+171 ;; _____________________________________________________________________________
+172 ;;
+173 ;; d. Relevant Legal and Behavioral history (pre-military, military, and post-
+174 ;; military): __________________________________________________________________
+175 ;;
+176 ;; e. Relevant Substance abuse history (pre-military, military, and post-
+177 ;; military): __________________________________________________________________
+178 ;;
+179 ;; f. Sentinel Event(s) (other than stressors): ________________________________
+180 ;; _____________________________________________________________________________
+181 ;;
+182 ;; g. Other, if any: ___________________________________________________________
+183 ;;^TOF^
+184 ;; 3. Symptoms
+185 ;; For VA rating purposes, check all symptoms that apply to the Veteran's
+186 ;; diagnoses:
+187 ;; ___ Depressed mood
+188 ;; ___ Anxiety
+189 ;; ___ Suspiciousness
+190 ;; ___ Panic attacks that occur weekly or less often
+191 ;; ___ Panic attacks more than once a week
+192 ;; ___ Near-continuous panic or depression affecting the ability to function
+193 ;; independently, appropriately and effectively
+194 ;; ___ Chronic sleep impairment
+195 ;; ___ Mild memory loss, such as forgetting names, directions or recent events
+196 ;; ___ Impairment of short- and long-term memory, for example, retention of
+197 ;; only highly learned material, while forgetting to complete tasks
+198 ;; ___ Memory loss for names of close relatives, own occupation, or own name
+199 ;; ___ Flattened affect
+200 ;; ___ Circumstantial, circumlocutory or stereotyped speech
+201 ;; ___ Speech intermittently illogical, obscure, or irrelevant
+202 ;; ___ Difficulty in understanding complex commands
+203 ;; ___ Impaired judgment
+204 ;; ___ Impaired abstract thinking
+205 ;; ___ Gross impairment in thought processes or communication
+206 ;; ___ Disturbances of motivation and mood
+207 ;; ___ Difficulty in establishing and maintaining effective work and social
+208 ;; relationships
+209 ;; ___ Difficulty in adapting to stressful circumstances, including work or a
+210 ;; worklike setting
+211 ;; ___ Inability to establish and maintain effective relationships
+212 ;; ___ Suicidal ideation
+213 ;; ___ Obsessional rituals which interfere with routine activities
+214 ;; ___ Impaired impulse control, such as unprovoked irritability with periods
+215 ;; of violence
+216 ;; ___ Spatial disorientation
+217 ;; ___ Persistent delusions or hallucinations
+218 ;; ___ Grossly inappropriate behavior
+219 ;; ___ Persistent danger of hurting self or others
+220 ;; ___ Neglect of personal appearance and hygiene
+221 ;; ___ Intermittent inability to perform activities of daily living,
+222 ;; including maintenance of minimal personal hygiene
+223 ;; ___ Disorientation to time or place
+224 ;;^TOF^
+225 ;; 4. Other symptoms
+226 ;; Does the Veteran have any other symptoms attributable to mental disorders
+227 ;; that are not listed above?
+228 ;; ___ Yes ___ No
+229 ;; If yes, describe: ___________________________________________________________
+230 ;;
+231 ;; 5. Competency
+232 ;; Is the Veteran capable of managing his or her financial affairs?
+233 ;; ___ Yes ___ No
+234 ;; If no, explain: _____________________________________________________________
+235 ;;
+236 ;; 6. Remarks, if any: _________________________________________________________
+237 ;;
+238 ;; Psychiatrist/Psychologist signature & title: _______________________________
+239 ;;
+240 ;; Psychiatrist/Psychologist printed name: ____________________________________
+241 ;;
+242 ;; Date: ________________________ Phone: ____________________________________
+243 ;;
+244 ;; License #: ___________________ Fax: ______________________________________
+245 ;;
+246 ;; Psychiatrist/Psychologist address: _________________________________________
+247 ;;
+248 ;; NOTE: VA may request additional medical information, including additional
+249 ;; examinations if necessary to complete VA's review of the Veteran's application.
+250 ;;^END^
+251 QUIT
