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Routine: DVBCQMD4

DVBCQMD4.m

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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^
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