DVBCQNM2 ;;ALB-CIOFO/ECF - HEADACHES INCLUDING MIGRAINE QUESTIONNAIRE ; 6/30/2011
;;2.7;AMIE;**174**;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.
;;
;; 1. Diagnosis
;;
;; Does the Veteran now have or has he/she ever been diagnosed with a headache
;; condition?
;;___ Yes ___ No
;;
;; If yes, select the Veteran's condition (check all that apply):
;; ___ Migraine including migraine variants
;; ICD code: ___ Date of diagnosis: _________
;; ___ Tension ICD code: ___ Date of diagnosis: _________
;; ___ Cluster ICD code: ___ Date of diagnosis: _________
;; ___ Other (specify type of headache): ____________________________________
;; ICD code: ___ Date of diagnosis: _________
;;
;; Other diagnosis #1: ______________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; Other diagnosis #2: ______________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; If there are additional diagnoses that pertain to a headache condition,
;; list using above format: ___________________________________________________
;;
;; 2. Medical History
;;
;; a. Describe the history (including onset and course) of the Veteran's
;; headache conditions (brief summary): _______________________________________
;;
;; b. Does the Veteran's treatment plan include taking medication for the
;; diagnosed condition?
;; ___ Yes ___ No
;; If yes, describe treatment (list only those medications used for the
;; diagnosed condition): _____________________________________________________
;;^TOF^
;; 3. Symptoms
;;
;; a. Does the Veteran experience headache pain?
;; ___ Yes ___ No
;; If yes, check all that apply to headache pain:
;; ___ Constant head pain
;; ___ Pulsating or throbbing head pain
;; ___ Pain localized to one side of the head
;; ___ Pain on both sides of the head
;; ___ Pain worsens with physical activity
;; ___ Other, describe: __________________________________________________
;;
;; b. Does the Veteran experience non-headache symptoms associated with
;; headaches? (including symptoms associated with an aura prior to headache
;; pain)
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Nausea
;; ___ Vomiting
;; ___ Sensitivity to light
;; ___ Sensitivity to sound
;; ___ Changes in vision (such as scotoma, flashes of light, tunnel vision)
;; ___ Sensory changes (such as feeling of pins and needles in extremities)
;; ___ Other, describe: ____________________________________________________
;;
;; c. Indicate duration of typical head pain
;; ___ Less than 1 day
;; ___ 1-2 days
;; ___ More than 2 days
;; ___ Other, describe: ____________________________________________________
;;
;; d. Indicate location of typical head pain
;; ___ Right side of head
;; ___ Left side of head
;; ___ Both sides of head
;; ___ Other, describe: _____________________________________________________
;;
;; 4. Prostrating attacks of headache pain
;;
;; a. Migraine - Does the Veteran have characteristic prostrating attacks of
;; migraine headache pain?
;; ___ Yes ___ No
;; If yes, indicate frequency, on average, of prostrating attacks over the last
;; several months:
;; ___ Less than once every 2 months
;; ___ Once in 2 months
;; ___ Once every month
;; ___ More frequently than once per month
;;^TOF^
;; b. Does the Veteran have very frequent prostrating and prolonged attacks of
;; migraine headache pain?
;; ___ Yes ___ No
;;
;; c. Non-Migraine - Does the Veteran have prostrating attacks of non-migraine
;; headache pain?
;; ___ Yes ___ No
;; If yes, indicate frequency, on average, of prostrating attacks over the last
;; several months:
;; ___ Less than once every 2 months
;; ___ Once in 2 months
;; ___ Once every month
;; ___ More frequently than once per month
;;
;; d. Does the Veteran have very frequent prostrating and prolonged attacks of
;; non-migraine headache pain?
;; ___ Yes ___ No
;;
;; 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. Diagnostic testing
;;
;; NOTE: Diagnostic testing is not required for this examination report; if
;; studies have already been completed, provide the most recent results below.
;;
;; 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):
;; ____________________________________________________________________________
;;^TOF^
;; 7. Functional impact
;;
;; Does the Veteran's headache condition impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe impact of the Veteran's headache condition, providing one
;; or more examples: __________________________________________________________
;;
;; 8. Remarks, if any: ________________________________________________________
;;
;; Physician signature: ____________________________________ Date: ____________
;;
;; Physician printed name: _________________________________ Phone: ___________
;;
;; Medical license #: ______________________________________ FAX: _____________
;;
;; Physician address: _________________________________________________________
;;
;; 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[HDVBCQNM2 6709 printed Nov 22, 2024@16:57:41 Page 2
DVBCQNM2 ;;ALB-CIOFO/ECF - HEADACHES INCLUDING MIGRAINE QUESTIONNAIRE ; 6/30/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran now have or has he/she ever been diagnosed with a headache
+10 ;; condition?
+11 ;;___ Yes ___ No
+12 ;;
+13 ;; If yes, select the Veteran's condition (check all that apply):
+14 ;; ___ Migraine including migraine variants
+15 ;; ICD code: ___ Date of diagnosis: _________
+16 ;; ___ Tension ICD code: ___ Date of diagnosis: _________
+17 ;; ___ Cluster ICD code: ___ Date of diagnosis: _________
+18 ;; ___ Other (specify type of headache): ____________________________________
+19 ;; ICD code: ___ Date of diagnosis: _________
+20 ;;
+21 ;; Other diagnosis #1: ______________
+22 ;; ICD code: ________________________
+23 ;; Date of diagnosis: _______________
+24 ;;
+25 ;; Other diagnosis #2: ______________
+26 ;; ICD code: ________________________
+27 ;; Date of diagnosis: _______________
+28 ;;
+29 ;; If there are additional diagnoses that pertain to a headache condition,
+30 ;; list using above format: ___________________________________________________
+31 ;;
+32 ;; 2. Medical History
+33 ;;
+34 ;; a. Describe the history (including onset and course) of the Veteran's
+35 ;; headache conditions (brief summary): _______________________________________
+36 ;;
+37 ;; b. Does the Veteran's treatment plan include taking medication for the
+38 ;; diagnosed condition?
+39 ;; ___ Yes ___ No
+40 ;; If yes, describe treatment (list only those medications used for the
+41 ;; diagnosed condition): _____________________________________________________
+42 ;;^TOF^
+43 ;; 3. Symptoms
+44 ;;
+45 ;; a. Does the Veteran experience headache pain?
+46 ;; ___ Yes ___ No
+47 ;; If yes, check all that apply to headache pain:
+48 ;; ___ Constant head pain
+49 ;; ___ Pulsating or throbbing head pain
+50 ;; ___ Pain localized to one side of the head
+51 ;; ___ Pain on both sides of the head
+52 ;; ___ Pain worsens with physical activity
+53 ;; ___ Other, describe: __________________________________________________
+54 ;;
+55 ;; b. Does the Veteran experience non-headache symptoms associated with
+56 ;; headaches? (including symptoms associated with an aura prior to headache
+57 ;; pain)
+58 ;; ___ Yes ___ No
+59 ;; If yes, check all that apply:
+60 ;; ___ Nausea
+61 ;; ___ Vomiting
+62 ;; ___ Sensitivity to light
+63 ;; ___ Sensitivity to sound
+64 ;; ___ Changes in vision (such as scotoma, flashes of light, tunnel vision)
+65 ;; ___ Sensory changes (such as feeling of pins and needles in extremities)
+66 ;; ___ Other, describe: ____________________________________________________
+67 ;;
+68 ;; c. Indicate duration of typical head pain
+69 ;; ___ Less than 1 day
+70 ;; ___ 1-2 days
+71 ;; ___ More than 2 days
+72 ;; ___ Other, describe: ____________________________________________________
+73 ;;
+74 ;; d. Indicate location of typical head pain
+75 ;; ___ Right side of head
+76 ;; ___ Left side of head
+77 ;; ___ Both sides of head
+78 ;; ___ Other, describe: _____________________________________________________
+79 ;;
+80 ;; 4. Prostrating attacks of headache pain
+81 ;;
+82 ;; a. Migraine - Does the Veteran have characteristic prostrating attacks of
+83 ;; migraine headache pain?
+84 ;; ___ Yes ___ No
+85 ;; If yes, indicate frequency, on average, of prostrating attacks over the last
+86 ;; several months:
+87 ;; ___ Less than once every 2 months
+88 ;; ___ Once in 2 months
+89 ;; ___ Once every month
+90 ;; ___ More frequently than once per month
+91 ;;^TOF^
+92 ;; b. Does the Veteran have very frequent prostrating and prolonged attacks of
+93 ;; migraine headache pain?
+94 ;; ___ Yes ___ No
+95 ;;
+96 ;; c. Non-Migraine - Does the Veteran have prostrating attacks of non-migraine
+97 ;; headache pain?
+98 ;; ___ Yes ___ No
+99 ;; If yes, indicate frequency, on average, of prostrating attacks over the last
+100 ;; several months:
+101 ;; ___ Less than once every 2 months
+102 ;; ___ Once in 2 months
+103 ;; ___ Once every month
+104 ;; ___ More frequently than once per month
+105 ;;
+106 ;; d. Does the Veteran have very frequent prostrating and prolonged attacks of
+107 ;; non-migraine headache pain?
+108 ;; ___ Yes ___ No
+109 ;;
+110 ;; 5. Other pertinent physical findings, complications, conditions, signs
+111 ;; and/or symptoms
+112 ;;
+113 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+114 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+115 ;; section above?
+116 ;; ___ Yes ___ No
+117 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+118 ;; of all related scars greater than 39 square cm (6 square inches)?
+119 ;; ___ Yes ___ No
+120 ;; If yes, also complete a Scars Questionnaire.
+121 ;;
+122 ;; b. Does the Veteran have any other pertinent physical findings,
+123 ;; complications, conditions, signs and/or symptoms related to any conditions
+124 ;; listed in the Diagnosis section above?
+125 ;; ___ Yes ___ No
+126 ;; If yes, describe (brief summary): __________________________________________
+127 ;;
+128 ;; 6. Diagnostic testing
+129 ;;
+130 ;; NOTE: Diagnostic testing is not required for this examination report; if
+131 ;; studies have already been completed, provide the most recent results below.
+132 ;;
+133 ;; Are there any other significant diagnostic test findings and/or results?
+134 ;; ___ Yes ___ No
+135 ;; If yes, provide type of test or procedure, date and results (brief summary):
+136 ;; ____________________________________________________________________________
+137 ;;^TOF^
+138 ;; 7. Functional impact
+139 ;;
+140 ;; Does the Veteran's headache condition impact his or her ability to work?
+141 ;; ___ Yes ___ No
+142 ;; If yes, describe impact of the Veteran's headache condition, providing one
+143 ;; or more examples: __________________________________________________________
+144 ;;
+145 ;; 8. Remarks, if any: ________________________________________________________
+146 ;;
+147 ;; Physician signature: ____________________________________ Date: ____________
+148 ;;
+149 ;; Physician printed name: _________________________________ Phone: ___________
+150 ;;
+151 ;; Medical license #: ______________________________________ FAX: _____________
+152 ;;
+153 ;; Physician address: _________________________________________________________
+154 ;;
+155 ;; NOTE: VA may request additional medical information, including additional
+156 ;; examinations if necessary to complete VA's review of the Veteran's
+157 ;; application.
+158 ;;^END^
+159 QUIT
