DVBCQMS3 ;;ALB-CIOFO/ECF - MULTIPLE SCLEROSIS QUESTIONNAIRE ; 5/10/2011
;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
;
TXT ;
;;^TOF^
;; 5. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;;
;; a. Does the Veteran have any scars (surgical or otherwise) related to any
;; conditions or to the treatment of any conditions listed in the Diagnosis
;; section above?
;; ___ Yes ___ No
;; If yes, are any of the scars painful and/or unstable, or is the total area
;; of all related scars greater than 39 square cm (6 square inches)?
;; ___ Yes ___ No
;; If yes, also complete a Scars Questionnaire.
;;
;; b. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs and/or symptoms related to any conditions
;; listed in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): __________________________________________
;;
;; 6. Mental health manifestations due to multiple sclerosis or its treatment
;;
;; a. Does the Veteran have signs or symptoms of depression, cognitive
;; impairment or dementia, or any other mental disorder attributable to MS
;; and/or its treatment?
;; ___ Yes ___ No
;;
;; If yes, briefly describe: __________________________________________________
;; If yes, also complete a Mental Disorder DBQ (schedule with appropriate
;; provider).
;;
;; b. Does the Veteran's mental disorder, as identified in the question above,
;; result in gross impairment in thought processes or communication?
;; ___ Yes ___ No
;; If No, also complete a Mental Disorder Questionnaire (schedule with
;; appropriate provider).
;; If yes, briefly describe the signs and symptoms of the Veteran's mental
;; disorder: _________________________________________________________________
;;
;; 7. Housebound
;;
;; a. Is the Veteran substantially confined to his or her dwelling and the
;; immediate premises (or if institutionalized, to the ward or clinical areas)?
;; ___ Yes ___ No
;; If yes, describe how often per day or week and under what circumstances the
;; Veteran is able to leave the home or immediate premises: ___________________
;;^TOF^
;; b. If yes, does the Veteran have more than one condition contributing to his
;; or her being housebound?
;; ___ Yes ___ No
;; If yes, list conditions and describe how each condition contributes to
;; causing the Veteran to be housebound:
;;
;; Condition #1: ______________________________________________________________
;; Describe how condition #1 contributes to causing the Veteran to be
;; housebound: ________________________________________________________________
;;
;; Condition #2: ______________________________________________________________
;; Describe how condition #2 contributes to causing the Veteran to be
;; housebound: ________________________________________________________________
;;
;; Condition #3: ______________________________________________________________
;; Describe how condition #3 contributes to causing the Veteran to be
;; housebound: ________________________________________________________________
;;
;; c. If the Veteran has additional conditions contributing to causing the
;; Veteran to be housebound, list using above format: _________________________
;;
;; 8. Aid & Attendance
;;
;; a. Is the Veteran able to dress or undress without assistance?
;; ___ Yes ___ No
;; If no, is this limitation caused by the Veteran's MS?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have sufficient upper extremity coordination and
;; strength to be able to feed him or herself without assistance?
;; ___ Yes ___ No
;; If no, is this limitation caused by the Veteran's MS?
;; ___ Yes ___ No
;;
;; c. Is the Veteran able to prepare meals without assistance?
;; ___ Yes ___ No
;; If no, is this limitation caused by the Veteran's MS?
;; ___ Yes ___ No
;;
;; d. Is the Veteran able to attend to the wants of nature (toileting)
;; without assistance?
;; ___ Yes ___ No
;; If no, is this limitation caused by the Veteran's MS?
;; ___ Yes ___ No
;;
;; e. Is the Veteran able to bathe him or herself without assistance?
;; ___ Yes ___ No
;; If no, is this limitation caused by the Veteran's MS?
;; ___ Yes ___ No
;;^TOF^
;; f. Is the Veteran able to keep him or herself ordinarily clean and
;; presentable without assistance?
;; ___ Yes ___ No
;; If no, is this limitation caused by the Veteran's MS?
;; ___ Yes ___ No
;;
;; g. Is the Veteran able to take prescription medications in a timely
;; manner and with accurate dosage without assistance?
;; ___ Yes ___ No
;; If no, is this limitation caused by the Veteran's MS?
;; ___ Yes ___ No
;;
;; h. Does the Veteran need frequent assistance for adjustment of any
;; special prosthetic or orthopedic appliance(s)?
;; ___ Yes ___ No
;; If yes, describe: __________________________________________________________
;;
;; NOTE: For VA purposes, "bedridden" will be that condition which actually
;; requires that the claimant remain in bed. The fact that claimant has
;; voluntarily taken to bed or that a physician has prescribed rest in bed for
;; the greater or lesser part of the day to promote convalescence or cure will
;; not suffice.
;;
;; i. Is the Veteran bedridden?
;; ___ Yes ___ No
;; If yes, is it due to the Veteran's MS?
;; ___ Yes ___ No
;;
;; j. Is the Veteran legally blind?
;; ___ Yes ___ No
;; If yes, is it due to the Veteran's MS?
;; ___ Yes ___ No
;; Provide best corrected vision, if known
;; Left Eye: _________ Right Eye: _____________
;;
;; k. Does the Veteran require care and/or assistance on a regular basis due to
;; his or her physical and/or mental disabilities in order to protect him or
;; herself from the hazards and/or dangers incident to his or her daily
;; environment?
;; ___ Yes ___ No
;; If yes, describe:_______________________________________________________
;; If yes, is it due to the Veteran's MS?
;; ___ Yes ___ No
;;
;; l. List any condition(s), in addition to the Veteran's MS, that causes any
;; of the above limitations: __________________________________________________
;;^TOF^
;; 9. Need for higher level (i.e., more skilled) A&A
;;
;; a. Does the Veteran require a higher, more skilled level of A&A?
;; ___ Yes ___ No
;; If yes, describe what type of care: ________________________________________
;; NOTE: For VA purposes, this skilled, higher level care includes (but is not
;; limited to) health-care services such as physical therapy, administration
;; of injections, placement of indwelling catheters, changing of sterile
;; dressings, and/or like functions which require professional health-care
;; training or the regular supervision of a trained health-care professional to
;; perform. In the absence of this higher level of care provided in the home,
;; the Veteran would require hospitalization, nursing home care, or other
;; residential institutional care.
;;
;;10. Assistive devices
;;
;; a. Does the Veteran use any assistive device(s) as a normal mode of
;; locomotion, although occasional locomotion by other methods may be possible?
;; ___ Yes ___ No
;;
;; If yes, identify assistive device(s) used (check all that apply and indicate
;; frequency):
;; __ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
;; __ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
;; __ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
;; __ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
;; __ Walker Frequency of use: __ Occasional __ Regular __ Constant
;; __ Other: ________________________________________________________________
;; Frequency of use: __ Occasional __ Regular __ Constant
;;
;; b. If the Veteran uses any assistive devices, specify the condition and
;; identify the assistive device used for each condition: _____________________
;;
;; 11. Remaining effective function of the extremities
;;
;; Due to MS, is there functional impairment of an extremity such that no
;; effective function remains other than that which would be equally well
;; served by an amputation with prosthesis? (Functions of the upper extremity
;; include grasping, manipulation, etc., while functions for the lower
;; extremity include balance and propulsion, etc.)
;; ___ Yes, functioning is so diminished that amputation with prosthesis would
;; equally serve the Veteran.
;; ___ No
;; If yes, indicate extremity(ies) (check all extremities for which this
;; applies):
;; ___ Right upper ___ Left upper ___ Right lower ___ Left lower
;; For each checked extremity, describe loss of effective function,
;; identify the condition causing loss of function, and provide specific
;; examples (brief summary): ______________________________________________
;;^TOF^
;;
;; 12. Financial responsibility
;;
;; In your judgment, is the Veteran able to manage his/her benefit payments in
;; his/her own best interest, or able to direct someone else to do so?
;; ___ Yes ___ No
;; If no, please describe: ____________________________________________________
;;
;; 13. Diagnostic testing
;;
;; NOTE: If the results of MRI, other imaging studies or other diagnostic tests
;; are in the medical record and reflect the Veteran's current condition,
;; repeat testing is not required. If pulmonary function testing (PFT) is
;; indicated due to respiratory disability, and results are in the medical
;; record and reflect the Veteran's current respiratory function, repeat
;; testing is not required. DLCO and bronchodilator testing is not indicated
;; for a restrictive respiratory disability such as that caused by muscle
;; weakness due to MS.
;;
;; a. Have imaging studies been performed?
;; ___ Yes ___ No
;; If yes, provide most recent results, if available: _________________________
;;
;; b. Have PFTs been performed?
;; ___ Yes ___ No
;; If yes, provide most recent results, if available:
;; FEV-1: ____________% predicted Date of test: _____________
;; FEV-1/FVC: ________% predicted Date of test: _____________
;; FEV: ______________% predicted Date of test: _____________
;;
;; c. If PFTs have been performed, is the flow-volume loop compatible with
;; upper airway obstruction?
;; ___ Yes ___ No
;;
;; d. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;
;; 14. Functional impact
;;
;; Does the Veteran's MS impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe impact of the Veteran's MS, providing one or more examples:
;; ____________________________________________________________________________
;;^TOF^
;; 15. Remarks, if any: _______________________________________________________
;;
;; Physician signature: ____________________________________ Date: ____________
;;
;; Physician printed name: ____________________________________________________
;;
;; Medical license #: _________________________________________________________
;;
;; Physician address: _________________________________________________________
;;
;; Phone: _____________________________ FAX: ______________________________
;;
;; 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[HDVBCQMS3 12118 printed Oct 16, 2024@17:48:16 Page 2
DVBCQMS3 ;;ALB-CIOFO/ECF - MULTIPLE SCLEROSIS QUESTIONNAIRE ; 5/10/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;;^TOF^
+2 ;; 5. Other pertinent physical findings, complications, conditions, signs
+3 ;; and/or symptoms
+4 ;;
+5 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+6 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+7 ;; section above?
+8 ;; ___ Yes ___ No
+9 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+10 ;; of all related scars greater than 39 square cm (6 square inches)?
+11 ;; ___ Yes ___ No
+12 ;; If yes, also complete a Scars Questionnaire.
+13 ;;
+14 ;; b. Does the Veteran have any other pertinent physical findings,
+15 ;; complications, conditions, signs and/or symptoms related to any conditions
+16 ;; listed in the Diagnosis section above?
+17 ;; ___ Yes ___ No
+18 ;; If yes, describe (brief summary): __________________________________________
+19 ;;
+20 ;; 6. Mental health manifestations due to multiple sclerosis or its treatment
+21 ;;
+22 ;; a. Does the Veteran have signs or symptoms of depression, cognitive
+23 ;; impairment or dementia, or any other mental disorder attributable to MS
+24 ;; and/or its treatment?
+25 ;; ___ Yes ___ No
+26 ;;
+27 ;; If yes, briefly describe: __________________________________________________
+28 ;; If yes, also complete a Mental Disorder DBQ (schedule with appropriate
+29 ;; provider).
+30 ;;
+31 ;; b. Does the Veteran's mental disorder, as identified in the question above,
+32 ;; result in gross impairment in thought processes or communication?
+33 ;; ___ Yes ___ No
+34 ;; If No, also complete a Mental Disorder Questionnaire (schedule with
+35 ;; appropriate provider).
+36 ;; If yes, briefly describe the signs and symptoms of the Veteran's mental
+37 ;; disorder: _________________________________________________________________
+38 ;;
+39 ;; 7. Housebound
+40 ;;
+41 ;; a. Is the Veteran substantially confined to his or her dwelling and the
+42 ;; immediate premises (or if institutionalized, to the ward or clinical areas)?
+43 ;; ___ Yes ___ No
+44 ;; If yes, describe how often per day or week and under what circumstances the
+45 ;; Veteran is able to leave the home or immediate premises: ___________________
+46 ;;^TOF^
+47 ;; b. If yes, does the Veteran have more than one condition contributing to his
+48 ;; or her being housebound?
+49 ;; ___ Yes ___ No
+50 ;; If yes, list conditions and describe how each condition contributes to
+51 ;; causing the Veteran to be housebound:
+52 ;;
+53 ;; Condition #1: ______________________________________________________________
+54 ;; Describe how condition #1 contributes to causing the Veteran to be
+55 ;; housebound: ________________________________________________________________
+56 ;;
+57 ;; Condition #2: ______________________________________________________________
+58 ;; Describe how condition #2 contributes to causing the Veteran to be
+59 ;; housebound: ________________________________________________________________
+60 ;;
+61 ;; Condition #3: ______________________________________________________________
+62 ;; Describe how condition #3 contributes to causing the Veteran to be
+63 ;; housebound: ________________________________________________________________
+64 ;;
+65 ;; c. If the Veteran has additional conditions contributing to causing the
+66 ;; Veteran to be housebound, list using above format: _________________________
+67 ;;
+68 ;; 8. Aid & Attendance
+69 ;;
+70 ;; a. Is the Veteran able to dress or undress without assistance?
+71 ;; ___ Yes ___ No
+72 ;; If no, is this limitation caused by the Veteran's MS?
+73 ;; ___ Yes ___ No
+74 ;;
+75 ;; b. Does the Veteran have sufficient upper extremity coordination and
+76 ;; strength to be able to feed him or herself without assistance?
+77 ;; ___ Yes ___ No
+78 ;; If no, is this limitation caused by the Veteran's MS?
+79 ;; ___ Yes ___ No
+80 ;;
+81 ;; c. Is the Veteran able to prepare meals without assistance?
+82 ;; ___ Yes ___ No
+83 ;; If no, is this limitation caused by the Veteran's MS?
+84 ;; ___ Yes ___ No
+85 ;;
+86 ;; d. Is the Veteran able to attend to the wants of nature (toileting)
+87 ;; without assistance?
+88 ;; ___ Yes ___ No
+89 ;; If no, is this limitation caused by the Veteran's MS?
+90 ;; ___ Yes ___ No
+91 ;;
+92 ;; e. Is the Veteran able to bathe him or herself without assistance?
+93 ;; ___ Yes ___ No
+94 ;; If no, is this limitation caused by the Veteran's MS?
+95 ;; ___ Yes ___ No
+96 ;;^TOF^
+97 ;; f. Is the Veteran able to keep him or herself ordinarily clean and
+98 ;; presentable without assistance?
+99 ;; ___ Yes ___ No
+100 ;; If no, is this limitation caused by the Veteran's MS?
+101 ;; ___ Yes ___ No
+102 ;;
+103 ;; g. Is the Veteran able to take prescription medications in a timely
+104 ;; manner and with accurate dosage without assistance?
+105 ;; ___ Yes ___ No
+106 ;; If no, is this limitation caused by the Veteran's MS?
+107 ;; ___ Yes ___ No
+108 ;;
+109 ;; h. Does the Veteran need frequent assistance for adjustment of any
+110 ;; special prosthetic or orthopedic appliance(s)?
+111 ;; ___ Yes ___ No
+112 ;; If yes, describe: __________________________________________________________
+113 ;;
+114 ;; NOTE: For VA purposes, "bedridden" will be that condition which actually
+115 ;; requires that the claimant remain in bed. The fact that claimant has
+116 ;; voluntarily taken to bed or that a physician has prescribed rest in bed for
+117 ;; the greater or lesser part of the day to promote convalescence or cure will
+118 ;; not suffice.
+119 ;;
+120 ;; i. Is the Veteran bedridden?
+121 ;; ___ Yes ___ No
+122 ;; If yes, is it due to the Veteran's MS?
+123 ;; ___ Yes ___ No
+124 ;;
+125 ;; j. Is the Veteran legally blind?
+126 ;; ___ Yes ___ No
+127 ;; If yes, is it due to the Veteran's MS?
+128 ;; ___ Yes ___ No
+129 ;; Provide best corrected vision, if known
+130 ;; Left Eye: _________ Right Eye: _____________
+131 ;;
+132 ;; k. Does the Veteran require care and/or assistance on a regular basis due to
+133 ;; his or her physical and/or mental disabilities in order to protect him or
+134 ;; herself from the hazards and/or dangers incident to his or her daily
+135 ;; environment?
+136 ;; ___ Yes ___ No
+137 ;; If yes, describe:_______________________________________________________
+138 ;; If yes, is it due to the Veteran's MS?
+139 ;; ___ Yes ___ No
+140 ;;
+141 ;; l. List any condition(s), in addition to the Veteran's MS, that causes any
+142 ;; of the above limitations: __________________________________________________
+143 ;;^TOF^
+144 ;; 9. Need for higher level (i.e., more skilled) A&A
+145 ;;
+146 ;; a. Does the Veteran require a higher, more skilled level of A&A?
+147 ;; ___ Yes ___ No
+148 ;; If yes, describe what type of care: ________________________________________
+149 ;; NOTE: For VA purposes, this skilled, higher level care includes (but is not
+150 ;; limited to) health-care services such as physical therapy, administration
+151 ;; of injections, placement of indwelling catheters, changing of sterile
+152 ;; dressings, and/or like functions which require professional health-care
+153 ;; training or the regular supervision of a trained health-care professional to
+154 ;; perform. In the absence of this higher level of care provided in the home,
+155 ;; the Veteran would require hospitalization, nursing home care, or other
+156 ;; residential institutional care.
+157 ;;
+158 ;;10. Assistive devices
+159 ;;
+160 ;; a. Does the Veteran use any assistive device(s) as a normal mode of
+161 ;; locomotion, although occasional locomotion by other methods may be possible?
+162 ;; ___ Yes ___ No
+163 ;;
+164 ;; If yes, identify assistive device(s) used (check all that apply and indicate
+165 ;; frequency):
+166 ;; __ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
+167 ;; __ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
+168 ;; __ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
+169 ;; __ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
+170 ;; __ Walker Frequency of use: __ Occasional __ Regular __ Constant
+171 ;; __ Other: ________________________________________________________________
+172 ;; Frequency of use: __ Occasional __ Regular __ Constant
+173 ;;
+174 ;; b. If the Veteran uses any assistive devices, specify the condition and
+175 ;; identify the assistive device used for each condition: _____________________
+176 ;;
+177 ;; 11. Remaining effective function of the extremities
+178 ;;
+179 ;; Due to MS, is there functional impairment of an extremity such that no
+180 ;; effective function remains other than that which would be equally well
+181 ;; served by an amputation with prosthesis? (Functions of the upper extremity
+182 ;; include grasping, manipulation, etc., while functions for the lower
+183 ;; extremity include balance and propulsion, etc.)
+184 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+185 ;; equally serve the Veteran.
+186 ;; ___ No
+187 ;; If yes, indicate extremity(ies) (check all extremities for which this
+188 ;; applies):
+189 ;; ___ Right upper ___ Left upper ___ Right lower ___ Left lower
+190 ;; For each checked extremity, describe loss of effective function,
+191 ;; identify the condition causing loss of function, and provide specific
+192 ;; examples (brief summary): ______________________________________________
+193 ;;^TOF^
+194 ;;
+195 ;; 12. Financial responsibility
+196 ;;
+197 ;; In your judgment, is the Veteran able to manage his/her benefit payments in
+198 ;; his/her own best interest, or able to direct someone else to do so?
+199 ;; ___ Yes ___ No
+200 ;; If no, please describe: ____________________________________________________
+201 ;;
+202 ;; 13. Diagnostic testing
+203 ;;
+204 ;; NOTE: If the results of MRI, other imaging studies or other diagnostic tests
+205 ;; are in the medical record and reflect the Veteran's current condition,
+206 ;; repeat testing is not required. If pulmonary function testing (PFT) is
+207 ;; indicated due to respiratory disability, and results are in the medical
+208 ;; record and reflect the Veteran's current respiratory function, repeat
+209 ;; testing is not required. DLCO and bronchodilator testing is not indicated
+210 ;; for a restrictive respiratory disability such as that caused by muscle
+211 ;; weakness due to MS.
+212 ;;
+213 ;; a. Have imaging studies been performed?
+214 ;; ___ Yes ___ No
+215 ;; If yes, provide most recent results, if available: _________________________
+216 ;;
+217 ;; b. Have PFTs been performed?
+218 ;; ___ Yes ___ No
+219 ;; If yes, provide most recent results, if available:
+220 ;; FEV-1: ____________% predicted Date of test: _____________
+221 ;; FEV-1/FVC: ________% predicted Date of test: _____________
+222 ;; FEV: ______________% predicted Date of test: _____________
+223 ;;
+224 ;; c. If PFTs have been performed, is the flow-volume loop compatible with
+225 ;; upper airway obstruction?
+226 ;; ___ Yes ___ No
+227 ;;
+228 ;; d. Are there any other significant diagnostic test findings and/or results?
+229 ;; ___ Yes ___ No
+230 ;; If yes, provide type of test or procedure, date and results (brief summary):
+231 ;; ____________________________________________________________________________
+232 ;;
+233 ;; 14. Functional impact
+234 ;;
+235 ;; Does the Veteran's MS impact his or her ability to work?
+236 ;; ___ Yes ___ No
+237 ;; If yes, describe impact of the Veteran's MS, providing one or more examples:
+238 ;; ____________________________________________________________________________
+239 ;;^TOF^
+240 ;; 15. Remarks, if any: _______________________________________________________
+241 ;;
+242 ;; Physician signature: ____________________________________ Date: ____________
+243 ;;
+244 ;; Physician printed name: ____________________________________________________
+245 ;;
+246 ;; Medical license #: _________________________________________________________
+247 ;;
+248 ;; Physician address: _________________________________________________________
+249 ;;
+250 ;; Phone: _____________________________ FAX: ______________________________
+251 ;;
+252 ;; NOTE: VA may request additional medical information, including additional
+253 ;; examinations if necessary to complete VA's review of the Veteran's
+254 ;; application.
+255 ;;^END^
+256 QUIT
