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Routine: DVBCQPD4

DVBCQPD4.m

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  1. DVBCQPD4 ;;ALB-CIOFO/ECF - PARKINSON'S QUESTIONNAIRE ; 10/6/2010
  1. ;;2.7;AMIE;**159**;Apr 10, 1995;Build 5
  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
  1. ;; Parkinson's disease? ___Yes ___No
  1. ;;
  1. ;; ICD code: _____________________________
  1. ;;
  1. ;; Date of diagnosis: ____________________
  1. ;;
  1. ;; 2. Dominant hand
  1. ;;
  1. ;; ___Right ___Left ___Ambidextrous
  1. ;;
  1. ;; 3. Motor manifestations due to Parkinson's or its treatment
  1. ;; (check all that apply)
  1. ;;
  1. ;; Stooped posture
  1. ;; ___None ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; Balance impairment
  1. ;; ___None ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; Bradykinesia or slowed motion (difficulty initiating movement, "freezing",
  1. ;; short shuffling steps)
  1. ;; ___None ___Mild __Moderate ___Severe
  1. ;;
  1. ;; Loss of automatic movements (such as blinking, leading to fixed gaze;
  1. ;; typical Parkinson's facies)
  1. ;; ___None ___Mild __Moderate ___Severe
  1. ;;
  1. ;; Speech changes (monotone, slurring words, soft or rapid speech)
  1. ;; ___None ___Mild __Moderate ___Severe
  1. ;;
  1. ;;^TOF^
  1. ;; Tremor (characteristic hand shaking, "pill-rolling")
  1. ;;
  1. ;; __Yes __No
  1. ;;
  1. ;; Extremities affected:
  1. ;;
  1. ;; __ Right upper
  1. ;; ___Not affected ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; __ Left upper
  1. ;; ___Not affected ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; __ Right lower
  1. ;; ___Not affected ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; __ Left lower
  1. ;; ___Not affected ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; Muscle rigidity and stiffness
  1. ;;
  1. ;; __Yes __No
  1. ;;
  1. ;; Extremities affected:
  1. ;;
  1. ;; __ Right upper
  1. ;; ___Not affected ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; __ Left upper
  1. ;; ___Not affected ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; __ Right lower
  1. ;; ___Not affected ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; __ Left lower
  1. ;; ___Not affected ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; 4. Mental manifestations due to Parkinson's or its treatment
  1. ;;
  1. ;; Depression
  1. ;; ___None ___Mild __Moderate ___Severe
  1. ;;
  1. ;; Cognitive impairment or dementia
  1. ;; ___None ___Mild __Moderate ___Severe
  1. ;;
  1. ;;^TOF^
  1. ;; 5. Additional manifestations/complications due to Parkinson's or its
  1. ;; treatment
  1. ;;
  1. ;; Loss of sense of smell
  1. ;;
  1. ;; __None __Partial __Complete
  1. ;;
  1. ;; Sleep disturbance (insomnia or daytime "sleep attacks")
  1. ;;
  1. ;; ___None ___Mild __Moderate ___Severe
  1. ;;
  1. ;; Difficulty chewing/swallowing
  1. ;;
  1. ;; ___None ___Mild __Moderate ___Severe
  1. ;;
  1. ;; Urinary problems __None __Incontinence __Urinary retention
  1. ;;
  1. ;; Absorbent material required, specify pads/day:
  1. ;;
  1. ;; __0 __1 __2-4 __> 4
  1. ;;
  1. ;; Use of an appliance required?
  1. ;;
  1. ;; __Yes __No
  1. ;;
  1. ;; Constipation (due to slowing of GI tract or secondary to Parkinson's
  1. ;; medications)
  1. ;;
  1. ;; ___None ___Mild __Moderate ___Severe
  1. ;;
  1. ;; Sexual dysfunction
  1. ;;
  1. ;; ___None ___Mild __Moderate ___Severe (precludes intercourse)
  1. ;;
  1. ;; __Erectile dysfunction precludes intercourse
  1. ;;
  1. ;; Other manifestations/complications:_____________________________________
  1. ;;
  1. ;; 6. Financial responsibility
  1. ;;
  1. ;; In your judgment, is the Veteran able to manage his/her benefit payments
  1. ;; in his/her own best interest, or able to direct someone else to
  1. ;; do so? ___Yes ___No
  1. ;;^TOF^
  1. ;; 7. Functional impact
  1. ;;
  1. ;; Does the Veteran's Parkinson's disease impact his or her ability to
  1. ;; work?
  1. ;;
  1. ;; ___Yes ___No
  1. ;;
  1. ;; If yes, describe impact, providing one or more examples:
  1. ;;
  1. ;; __________________________________________________________________________
  1. ;;
  1. ;; 8. Remarks, if any __________________________________________________________
  1. ;;
  1. ;; __________________________________________________________________________
  1. ;;
  1. ;; Physician signature: _____________________________________ Date: ____________
  1. ;;
  1. ;; Physician printed name: __________________________________ Phone: ___________
  1. ;;
  1. ;; Medical license #: __________________
  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. ;;
  1. ;;
  1. ;; ^END^
  1. Q