Home   Package List   Routine Alphabetical List   Global Alphabetical List   FileMan Files List   FileMan Sub-Files List   Package Component Lists   Package-Namespace Mapping  
Routine: DVBCQMD4

DVBCQMD4.m

Go to the documentation of this file. 
  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