- 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 Feb 18, 2025@23:13:35 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