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Routine: DVBCQMD4

DVBCQMD4.m

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  1. DVBCQMD4 ;;ALB-CIOFO/ECF,SBW - MENTAL DISORDERS QUESTIONNAIRE (v2) ; 15/JUNE/2011
  1. ;;2.7;AMIE;**171**;Apr 10, 1995;Build 2
  1. ;
  1. TXT ;
  1. ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1. ;; disability benefits. VA will consider the information you provide on this
  1. ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1. ;; Please note that this questionnaire is for disability evaluation, not for
  1. ;; treatment purposes.
  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 Veterans Crisis Line at
  1. ;; 1-800-273-TALK (8255). Stay on the Crisis Line 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. ;; This Questionnaire is to be completed for both initial and review mental
  1. ;; disorder(s) claims.
  1. ;;
  1. ;; SECTION I:
  1. ;; ----------
  1. ;;
  1. ;; 1. Diagnosis
  1. ;; a. Does the Veteran now have or has he/she ever been diagnosed with a mental
  1. ;; disorder(s)?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; NOTE: If the Veteran has a diagnosis of an eating disorder, complete the
  1. ;; Eating Disorders Questionnaire in lieu of this Questionnaire.
  1. ;; NOTE: If the Veteran has a diagnosis of PTSD, the Initial PTSD Questionnaire
  1. ;; must be completed by a VHA staff or contract examiner in lieu of this
  1. ;; Questionnaire.
  1. ;;^TOF^
  1. ;; If the Veteran currently has one or more mental disorders that conform to
  1. ;; DSM-IV criteria, provide all diagnoses:
  1. ;; Diagnosis #1: ______________________
  1. ;; ICD code: __________
  1. ;; Indicate the Axis category:
  1. ;; ___ Axis I ___ Axis II
  1. ;; Comments, if any: ___________________________________________________________
  1. ;;
  1. ;; Diagnosis #2: ______________________
  1. ;; ICD code: __________
  1. ;; Indicate the Axis category:
  1. ;; ___ Axis I ___ Axis II
  1. ;; Comments, if any: ___________________________________________________________
  1. ;;
  1. ;; Diagnosis #3: ______________________
  1. ;; ICD code: __________
  1. ;; Indicate the Axis category:
  1. ;; ___ Axis I ___ Axis II
  1. ;; Comments, if any: ___________________________________________________________
  1. ;;
  1. ;; If additional diagnoses that pertain to mental health disorders, list using
  1. ;; above format: _______________________________________________________________
  1. ;;
  1. ;; b. Axis III - medical diagnoses (to include TBI):
  1. ;; ICD code: __________
  1. ;; Comments, if any: ___________________________________________________________
  1. ;;
  1. ;; c. Axis IV - Psychosocial and Environmental Problems (describe, if any):
  1. ;; _____________________________________________________________________________
  1. ;;
  1. ;; d. Axis V - Current global assessment of functioning (GAF) score: ___________
  1. ;; Comments, if any: ___________________________________________________________
  1. ;;
  1. ;; 2. Differentiation of symptoms
  1. ;; a. Does the Veteran have more than one mental disorder diagnosed?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following question:
  1. ;;
  1. ;; b. Is it possible to differentiate what symptom(s) is/are attributable to
  1. ;; each diagnosis?
  1. ;; ___ Yes ___ No ___ Not applicable (N/A)
  1. ;; If no, provide reason that it is not possible to differentiate what portion
  1. ;; of each symptom is attributable to each diagnosis: __________________________
  1. ;; _____________________________________________________________________________
  1. ;; If yes, list which symptoms are attributable to each diagnosis: _____________
  1. ;; _____________________________________________________________________________
  1. ;;^TOF^
  1. ;; c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
  1. ;; ___ Yes ___ No ___ Not shown in records reviewed Comments, if any:
  1. ;; _____________________________________________________________________________
  1. ;; If yes, complete the following question:
  1. ;;
  1. ;; d. Is it possible to differentiate what symptom(s) is/are attributable to
  1. ;; each diagnosis?
  1. ;; ___ Yes ___ No ___ Not applicable (N/A)
  1. ;; If no, provide reason that it is not possible to differentiate what portion
  1. ;; of each symptom is attributable to each diagnosis: __________________________
  1. ;; _____________________________________________________________________________
  1. ;; If yes, list which symptoms are attributable to each diagnosis: _____________
  1. ;; _____________________________________________________________________________
  1. ;;
  1. ;; 3. Occupational and social impairment
  1. ;; a. Which of the following best summarizes the Veteran's level of occupational
  1. ;; and social impairment with regards to all mental diagnoses?
  1. ;; (Check only one)
  1. ;; ___ No mental disorder diagnosis
  1. ;; ___ A mental condition has been formally diagnosed, but symptoms are not
  1. ;; severe enough either to interfere with occupational and social functioning
  1. ;; or to require continuous medication
  1. ;; ___ Occupational and social impairment due to mild or transient symptoms which
  1. ;; decrease work efficiency and ability to perform occupational tasks only
  1. ;; during periods of significant stress, or; symptoms controlled by 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 routine
  1. ;; 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, such
  1. ;; as work, school, family relations, judgment, thinking and/or mood
  1. ;; ___ Total occupational and social impairment
  1. ;;
  1. ;; b. For the indicated level of occupational and social impairment, is it
  1. ;; possible to differentiate what portion of the occupational and social
  1. ;; impairment indicated above is caused by each mental disorder?
  1. ;; ___ Yes ___ No ___ No other mental disorder has been diagnosed
  1. ;; If no, provide reason that it is not possible to differentiate what portion
  1. ;; of the indicated level of occupational and social impairment is attributable
  1. ;; to each diagnosis: __________________________________________________________
  1. ;; If yes, list which portion of the indicated level of occupational and social
  1. ;; impairment is attributable to each diagnosis: _______________________________
  1. ;;^TOF^
  1. ;; c. If a diagnosis of TBI exists, is it possible to differentiate what portion
  1. ;; of the occupational and social impairment indicated above is caused by the TBI?
  1. ;; ___ Yes ___ No ___ No diagnosis of TBI
  1. ;; If no, provide reason that it is not possible to differentiate what portion
  1. ;; of the indicated level of occupational and social impairment is attributable
  1. ;; to each diagnosis: __________________________________________________________
  1. ;; If yes, list which portion of the indicated level of occupational and social
  1. ;; impairment is attributable to each diagnosis: _______________________________
  1. ;;
  1. ;; SECTION II:
  1. ;; -----------
  1. ;; Clinical Findings:
  1. ;; ------------------
  1. ;;
  1. ;; 1. Evidence review
  1. ;; If any records (evidence) were reviewed, please list here: __________________
  1. ;; _____________________________________________________________________________
  1. ;;
  1. ;; 2. History
  1. ;; NOTE: Initial examinations require pre-military, military, and post-military
  1. ;; history. If this is a review examination only indicate any relevant history
  1. ;; since prior exam.
  1. ;;
  1. ;; a. Relevant Social/Marital/Family history (pre-military, military, and post-
  1. ;; military): __________________________________________________________________
  1. ;;
  1. ;; b. Relevant Occupational and Educational history (pre-military, military, and
  1. ;; post-military): _____________________________________________________________
  1. ;;
  1. ;; c. Relevant Mental Health history, to include prescribed medications and
  1. ;; family mental health (pre-military, military, and post-military): ___________
  1. ;; _____________________________________________________________________________
  1. ;;
  1. ;; d. Relevant Legal and Behavioral history (pre-military, military, and post-
  1. ;; military): __________________________________________________________________
  1. ;;
  1. ;; e. Relevant Substance abuse history (pre-military, military, and post-
  1. ;; military): __________________________________________________________________
  1. ;;
  1. ;; f. Sentinel Event(s) (other than stressors): ________________________________
  1. ;; _____________________________________________________________________________
  1. ;;
  1. ;; g. Other, if any: ___________________________________________________________
  1. ;;^TOF^
  1. ;; 3. Symptoms
  1. ;; For VA rating purposes, check all symptoms that apply to the Veteran's
  1. ;; diagnoses:
  1. ;; ___ Depressed mood
  1. ;; ___ Anxiety
  1. ;; ___ Suspiciousness
  1. ;; ___ Panic attacks that occur weekly or less often
  1. ;; ___ Panic attacks more than once a week
  1. ;; ___ Near-continuous panic or depression affecting the ability to function
  1. ;; independently, appropriately and effectively
  1. ;; ___ Chronic sleep impairment
  1. ;; ___ Mild memory loss, such as forgetting names, directions or recent events
  1. ;; ___ Impairment of short- and long-term memory, for example, retention of
  1. ;; only highly learned material, while forgetting to complete tasks
  1. ;; ___ Memory loss for names of close relatives, own occupation, or own name
  1. ;; ___ Flattened affect
  1. ;; ___ Circumstantial, circumlocutory or stereotyped speech
  1. ;; ___ Speech intermittently illogical, obscure, or irrelevant
  1. ;; ___ Difficulty in understanding complex commands
  1. ;; ___ Impaired judgment
  1. ;; ___ Impaired abstract thinking
  1. ;; ___ Gross impairment in thought processes or communication
  1. ;; ___ Disturbances of motivation and mood
  1. ;; ___ Difficulty in establishing and maintaining effective work and social
  1. ;; relationships
  1. ;; ___ Difficulty in adapting to stressful circumstances, including work or a
  1. ;; worklike setting
  1. ;; ___ Inability to establish and maintain effective relationships
  1. ;; ___ Suicidal ideation
  1. ;; ___ Obsessional rituals which interfere with routine activities
  1. ;; ___ Impaired impulse control, such as unprovoked irritability with periods
  1. ;; of violence
  1. ;; ___ Spatial disorientation
  1. ;; ___ Persistent delusions or hallucinations
  1. ;; ___ Grossly inappropriate behavior
  1. ;; ___ Persistent danger of hurting self or others
  1. ;; ___ Neglect of personal appearance and hygiene
  1. ;; ___ Intermittent inability to perform activities of daily living,
  1. ;; including maintenance of minimal personal hygiene
  1. ;; ___ Disorientation to time or place
  1. ;;^TOF^
  1. ;; 4. Other symptoms
  1. ;; Does the Veteran have any other symptoms attributable to mental disorders
  1. ;; that are not listed above?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe: ___________________________________________________________
  1. ;;
  1. ;; 5. Competency
  1. ;; Is the Veteran capable of managing his or her financial affairs?
  1. ;; ___ Yes ___ No
  1. ;; If no, explain: _____________________________________________________________
  1. ;;
  1. ;; 6. Remarks, if any: _________________________________________________________
  1. ;;
  1. ;; Psychiatrist/Psychologist signature & title: _______________________________
  1. ;;
  1. ;; Psychiatrist/Psychologist printed name: ____________________________________
  1. ;;
  1. ;; Date: ________________________ Phone: ____________________________________
  1. ;;
  1. ;; License #: ___________________ Fax: ______________________________________
  1. ;;
  1. ;; Psychiatrist/Psychologist address: _________________________________________
  1. ;;
  1. ;; NOTE: VA may request additional medical information, including additional
  1. ;; examinations if necessary to complete VA's review of the Veteran's application.
  1. ;;^END^
  1. Q