Home   Package List   Routine Alphabetical List   Global Alphabetical List   FileMan Files List   FileMan Sub-Files List   Package Component Lists   Package-Namespace Mapping  
Routine: DVBCQMS3

DVBCQMS3.m

Go to the documentation of this file. 
  1. DVBCQMS3 ;;ALB-CIOFO/ECF - MULTIPLE SCLEROSIS QUESTIONNAIRE ; 5/10/2011
  1.  ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;;^TOF^
  1.  ;; 5. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, are any of the scars painful and/or unstable, or is the total area
  1.  ;; of all related scars greater than 39 square cm (6 square inches)?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If yes, also complete a Scars Questionnaire.
  1.  ;;
  1.  ;; b. Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs and/or symptoms related to any conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): __________________________________________
  1.  ;;
  1.  ;; 6. Mental health manifestations due to multiple sclerosis or its treatment
  1.  ;;
  1.  ;; a. Does the Veteran have signs or symptoms of depression, cognitive
  1.  ;; impairment or dementia, or any other mental disorder attributable to MS
  1.  ;; and/or its treatment?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, briefly describe: __________________________________________________
  1.  ;; If yes, also complete a Mental Disorder DBQ (schedule with appropriate
  1.  ;; provider).
  1.  ;;
  1.  ;; b.  Does the Veteran's mental disorder, as identified in the question above,
  1.  ;; result in gross impairment in thought processes or communication?
  1.  ;; ___ Yes   ___ No
  1.  ;;  If No, also complete a Mental Disorder Questionnaire (schedule with
  1.  ;;  appropriate provider).
  1.  ;;  If yes, briefly describe the signs and symptoms of the Veteran's mental
  1.  ;;  disorder: _________________________________________________________________
  1.  ;;
  1.  ;; 7. Housebound
  1.  ;;
  1.  ;; a. Is the Veteran substantially confined to his or her dwelling and the
  1.  ;; immediate premises (or if institutionalized, to the ward or clinical areas)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe how often per day or week and under what circumstances the
  1.  ;; Veteran is able to leave the home or immediate premises: ___________________
  1.  ;;^TOF^
  1.  ;; b. If yes, does the Veteran have more than one condition contributing to his
  1.  ;; or her being housebound?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, list conditions and describe how each condition contributes to
  1.  ;; causing the Veteran to be housebound:
  1.  ;;
  1.  ;; Condition #1: ______________________________________________________________
  1.  ;; Describe how condition #1 contributes to causing the Veteran to be
  1.  ;; housebound: ________________________________________________________________
  1.  ;;
  1.  ;; Condition #2: ______________________________________________________________
  1.  ;; Describe how condition #2 contributes to causing the Veteran to be
  1.  ;; housebound: ________________________________________________________________
  1.  ;;
  1.  ;; Condition #3: ______________________________________________________________
  1.  ;; Describe how condition #3 contributes to causing the Veteran to be
  1.  ;; housebound: ________________________________________________________________
  1.  ;; 
  1.  ;; c. If the Veteran has additional conditions contributing to causing the
  1.  ;; Veteran to be housebound, list using above format: _________________________
  1.  ;; 
  1.  ;; 8. Aid & Attendance
  1.  ;;
  1.  ;; a. Is the Veteran able to dress or undress without assistance?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If no, is this limitation caused by the Veteran's MS?
  1.  ;;     ___ Yes   ___ No
  1.  ;;
  1.  ;; b. Does the Veteran have sufficient upper extremity coordination and
  1.  ;; strength to be able to feed him or herself without assistance?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If no, is this limitation caused by the Veteran's MS?
  1.  ;;     ___ Yes   ___ No
  1.  ;;
  1.  ;; c. Is the Veteran able to prepare meals without assistance?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If no, is this limitation caused by the Veteran's MS?
  1.  ;;     ___ Yes   ___ No
  1.  ;;
  1.  ;; d.  Is the Veteran able to attend to the wants of nature (toileting)
  1.  ;; without assistance?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If no, is this limitation caused by the Veteran's MS?
  1.  ;;     ___ Yes   ___ No
  1.  ;;
  1.  ;; e. Is the Veteran able to bathe him or herself without assistance?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If no, is this limitation caused by the Veteran's MS?
  1.  ;;     ___ Yes   ___ No
  1.  ;;^TOF^
  1.  ;; f. Is the Veteran able to keep him or herself ordinarily clean and
  1.  ;; presentable without assistance?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If no, is this limitation caused by the Veteran's MS?
  1.  ;;     ___ Yes   ___ No
  1.  ;;
  1.  ;; g. Is the Veteran able to take prescription medications in a timely
  1.  ;; manner and with accurate dosage without assistance?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If no, is this limitation caused by the Veteran's MS?
  1.  ;;     ___ Yes   ___ No
  1.  ;;
  1.  ;; h. Does the Veteran need frequent assistance for adjustment of any
  1.  ;; special prosthetic or orthopedic appliance(s)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe: __________________________________________________________
  1.  ;;
  1.  ;; NOTE: For VA purposes, "bedridden" will be that condition which actually
  1.  ;; requires that the claimant remain in bed. The fact that claimant has
  1.  ;; voluntarily taken to bed or that a physician has prescribed rest in bed for
  1.  ;; the greater or lesser part of the day to promote convalescence or cure will
  1.  ;; not suffice.
  1.  ;;
  1.  ;; i. Is the Veteran bedridden?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If yes, is it due to the Veteran's MS?
  1.  ;;     ___ Yes   ___ No
  1.  ;;
  1.  ;; j. Is the Veteran legally blind?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If yes, is it due to the Veteran's MS?
  1.  ;;     ___ Yes   ___ No
  1.  ;;     Provide best corrected vision, if known
  1.  ;;     Left Eye: _________   Right Eye: _____________
  1.  ;;
  1.  ;; k. Does the Veteran require care and/or assistance on a regular basis due to
  1.  ;; his or her physical and/or mental disabilities in order to protect him or
  1.  ;; herself from the hazards and/or dangers incident to his or her daily
  1.  ;; environment?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe:_______________________________________________________
  1.  ;; If yes, is it due to the Veteran's MS?
  1.  ;;     ___ Yes   ___ No
  1.  ;;
  1.  ;; l. List any condition(s), in addition to the Veteran's MS, that causes any
  1.  ;; of the above limitations: __________________________________________________
  1.  ;;^TOF^
  1.  ;; 9. Need for higher level (i.e., more skilled) A&A
  1.  ;;
  1.  ;; a. Does the Veteran require a higher, more skilled level of A&A?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe what type of care: ________________________________________
  1.  ;; NOTE: For VA purposes, this skilled, higher level care includes (but is not
  1.  ;; limited to) health-care services such as physical therapy, administration
  1.  ;; of injections, placement of indwelling catheters, changing of sterile
  1.  ;; dressings, and/or like functions which require professional health-care
  1.  ;; training or the regular supervision of a trained health-care professional to
  1.  ;; perform. In the absence of this higher level of care provided in the home,
  1.  ;; the Veteran would require hospitalization, nursing home care, or other
  1.  ;; residential institutional care.
  1.  ;;
  1.  ;;10. Assistive devices
  1.  ;;
  1.  ;; a. Does the Veteran use any assistive device(s) as a normal mode of
  1.  ;; locomotion, although occasional locomotion by other methods may be possible?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, identify assistive device(s) used (check all that apply and indicate
  1.  ;; frequency):
  1.  ;;   __ Wheelchair  Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Brace(s)    Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Crutch(es)  Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Cane(s)     Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Walker      Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Other: ________________________________________________________________
  1.  ;;                  Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;
  1.  ;; b. If the Veteran uses any assistive devices, specify the condition and
  1.  ;; identify the assistive device used for each condition: _____________________
  1.  ;;
  1.  ;; 11. Remaining effective function of the extremities
  1.  ;;
  1.  ;; Due to MS, is there functional impairment of an extremity such that no
  1.  ;; effective function remains other than that which would be equally well
  1.  ;; served by an amputation with prosthesis? (Functions of the upper extremity
  1.  ;; include grasping, manipulation, etc., while functions for the lower
  1.  ;; extremity include balance and propulsion, etc.)
  1.  ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
  1.  ;; equally serve the Veteran.
  1.  ;; ___ No
  1.  ;;     If yes, indicate extremity(ies) (check all extremities for which this
  1.  ;;     applies):
  1.  ;;     ___ Right upper   ___ Left upper    ___ Right lower   ___ Left lower
  1.  ;;     For each checked extremity, describe loss of effective function,
  1.  ;;     identify the condition causing loss of function, and provide specific
  1.  ;;     examples (brief summary): ______________________________________________
  1.  ;;^TOF^
  1.  ;;
  1.  ;; 12. Financial responsibility
  1.  ;;
  1.  ;; In your judgment, is the Veteran able to manage his/her benefit payments in
  1.  ;; his/her own best interest, or able to direct someone else to do so?
  1.  ;; ___ Yes   ___ No
  1.  ;; If no, please describe: ____________________________________________________
  1.  ;;
  1.  ;; 13. Diagnostic testing
  1.  ;;
  1.  ;; NOTE: If the results of MRI, other imaging studies or other diagnostic tests
  1.  ;; are in the medical record and reflect the Veteran's current condition,
  1.  ;; repeat testing is not required. If pulmonary function testing (PFT) is
  1.  ;; indicated due to respiratory disability, and results are in the medical
  1.  ;; record and reflect the Veteran's current respiratory function, repeat
  1.  ;; testing is not required. DLCO and bronchodilator testing is not indicated
  1.  ;; for a restrictive respiratory disability such as that caused by muscle
  1.  ;; weakness due to MS.
  1.  ;;
  1.  ;; a. Have imaging studies been performed?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide most recent results, if available: _________________________
  1.  ;;
  1.  ;; b. Have PFTs been performed?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide most recent results, if available:
  1.  ;; FEV-1: ____________% predicted    Date of test: _____________
  1.  ;; FEV-1/FVC: ________% predicted    Date of test: _____________
  1.  ;; FEV: ______________% predicted    Date of test: _____________
  1.  ;;
  1.  ;; c. If PFTs have been performed, is the flow-volume loop compatible with
  1.  ;; upper airway obstruction?
  1.  ;; ___ Yes ___ No
  1.  ;;
  1.  ;; d. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 14. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's MS impact his or her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe impact of the Veteran's MS, providing one or more examples:
  1.  ;; ____________________________________________________________________________
  1.  ;;^TOF^
  1.  ;; 15. Remarks, if any: _______________________________________________________
  1.  ;;
  1.  ;; Physician signature: ____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: ____________________________________________________
  1.  ;;
  1.  ;; Medical license #: _________________________________________________________
  1.  ;;
  1.  ;; Physician address: _________________________________________________________
  1.  ;;
  1.  ;; Phone: _____________________________     FAX: ______________________________
  1.  ;;
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's
  1.  ;; application.
  1.  ;;^END^
  1.  Q