Home   Package List   Routine Alphabetical List   Global Alphabetical List   FileMan Files List   FileMan Sub-Files List   Package Component Lists   Package-Namespace Mapping  
Routine: DVBCQNM2

DVBCQNM2.m

Go to the documentation of this file. 
  1. DVBCQNM2 ;;ALB-CIOFO/ECF - HEADACHES INCLUDING MIGRAINE QUESTIONNAIRE ; 6/30/2011
  1.  ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs
  1.  ;; (VA) for disability benefits.  VA will consider the information you
  1.  ;; provide on this questionnaire as part of their evaluation in processing
  1.  ;; the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;;
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with a headache
  1.  ;; condition?
  1.  ;;___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, select the Veteran's condition (check all that apply):
  1.  ;;   ___ Migraine including migraine variants
  1.  ;;                       ICD code:  ___ Date of diagnosis: _________
  1.  ;;   ___ Tension         ICD code:  ___ Date of diagnosis: _________
  1.  ;;   ___ Cluster         ICD code:  ___ Date of diagnosis: _________
  1.  ;;   ___ Other (specify type of headache): ____________________________________
  1.  ;;                       ICD code:  ___ Date of diagnosis: _________
  1.  ;;
  1.  ;; Other diagnosis #1: ______________
  1.  ;; ICD code: ________________________
  1.  ;; Date of diagnosis: _______________
  1.  ;;
  1.  ;; Other diagnosis #2: ______________
  1.  ;; ICD code: ________________________
  1.  ;; Date of diagnosis: _______________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to a headache condition,
  1.  ;; list using above format: ___________________________________________________
  1.  ;;
  1.  ;; 2. Medical History
  1.  ;;
  1.  ;; a. Describe the history (including onset and course) of the Veteran's
  1.  ;; headache conditions (brief summary): _______________________________________
  1.  ;;
  1.  ;; b. Does the Veteran's treatment plan include taking medication for the
  1.  ;; diagnosed condition?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, describe treatment (list only those medications used for the
  1.  ;; diagnosed condition):  _____________________________________________________
  1.  ;;^TOF^
  1.  ;; 3. Symptoms
  1.  ;;
  1.  ;; a. Does the Veteran experience headache pain?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply to headache pain:
  1.  ;;    ___ Constant head pain
  1.  ;;    ___ Pulsating or throbbing head pain
  1.  ;;    ___ Pain localized to one side of the head
  1.  ;;    ___ Pain on both sides of the head
  1.  ;;    ___ Pain worsens with physical activity
  1.  ;;    ___ Other, describe: __________________________________________________  
  1.  ;;
  1.  ;; b. Does the Veteran experience non-headache symptoms associated with
  1.  ;; headaches? (including symptoms associated with an aura prior to headache
  1.  ;; pain)
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Nausea
  1.  ;;    ___ Vomiting
  1.  ;;    ___ Sensitivity to light
  1.  ;;    ___ Sensitivity to sound
  1.  ;;    ___ Changes in vision (such as scotoma, flashes of light, tunnel vision)
  1.  ;;    ___ Sensory changes (such as feeling of pins and needles in extremities)
  1.  ;;    ___ Other, describe: ____________________________________________________
  1.  ;;
  1.  ;; c. Indicate duration of typical head pain
  1.  ;;    ___ Less than 1 day
  1.  ;;    ___ 1-2 days
  1.  ;;    ___ More than 2 days
  1.  ;;    ___ Other, describe: ____________________________________________________
  1.  ;;
  1.  ;; d. Indicate location of typical head pain
  1.  ;;   ___ Right side of head
  1.  ;;   ___ Left side of head
  1.  ;;   ___ Both sides of head
  1.  ;;   ___ Other, describe: _____________________________________________________
  1.  ;;
  1.  ;; 4. Prostrating attacks of headache pain
  1.  ;;
  1.  ;; a. Migraine - Does the Veteran have characteristic prostrating attacks of
  1.  ;; migraine headache pain?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate frequency, on average, of prostrating attacks over the last
  1.  ;; several months:
  1.  ;;    ___ Less than once every 2 months
  1.  ;;    ___ Once in 2 months
  1.  ;;    ___ Once every month
  1.  ;;    ___ More frequently than once per month
  1.  ;;^TOF^
  1.  ;; b. Does the Veteran have very frequent prostrating and prolonged attacks of
  1.  ;; migraine headache pain?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; c. Non-Migraine - Does the Veteran have prostrating attacks of non-migraine
  1.  ;; headache pain?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate frequency, on average, of prostrating attacks over the last
  1.  ;; several months:
  1.  ;;    ___ Less than once every 2 months
  1.  ;;    ___ Once in 2 months
  1.  ;;    ___ Once every month
  1.  ;;    ___ More frequently than once per month
  1.  ;;
  1.  ;; d. Does the Veteran have very frequent prostrating and prolonged attacks of
  1.  ;; non-migraine headache pain?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  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. Diagnostic testing
  1.  ;;
  1.  ;; NOTE: Diagnostic testing is not required for this examination report; if
  1.  ;; studies have already been completed, provide the most recent results below. 
  1.  ;;
  1.  ;; 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.  ;;^TOF^
  1.  ;; 7. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's headache condition impact his or her ability to work?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, describe impact of the Veteran's headache condition, providing one
  1.  ;; or more examples: __________________________________________________________
  1.  ;;
  1.  ;; 8. Remarks, if any: ________________________________________________________
  1.  ;;
  1.  ;; Physician signature: ____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: _________________________________ Phone: ___________
  1.  ;;
  1.  ;; Medical license #: ______________________________________ FAX: _____________
  1.  ;;
  1.  ;; Physician 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
  1.  ;; application.
  1.  ;;^END^
  1.  Q