- DVBCQPD4 ;;ALB-CIOFO/ECF - PARKINSON'S QUESTIONNAIRE ; 10/6/2010
- ;;2.7;AMIE;**159**;Apr 10, 1995;Build 5
- ;
- 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
- ;; Parkinson's disease? ___Yes ___No
- ;;
- ;; ICD code: _____________________________
- ;;
- ;; Date of diagnosis: ____________________
- ;;
- ;; 2. Dominant hand
- ;;
- ;; ___Right ___Left ___Ambidextrous
- ;;
- ;; 3. Motor manifestations due to Parkinson's or its treatment
- ;; (check all that apply)
- ;;
- ;; Stooped posture
- ;; ___None ___Mild ___Moderate ___Severe
- ;;
- ;; Balance impairment
- ;; ___None ___Mild ___Moderate ___Severe
- ;;
- ;; Bradykinesia or slowed motion (difficulty initiating movement, "freezing",
- ;; short shuffling steps)
- ;; ___None ___Mild __Moderate ___Severe
- ;;
- ;; Loss of automatic movements (such as blinking, leading to fixed gaze;
- ;; typical Parkinson's facies)
- ;; ___None ___Mild __Moderate ___Severe
- ;;
- ;; Speech changes (monotone, slurring words, soft or rapid speech)
- ;; ___None ___Mild __Moderate ___Severe
- ;;
- ;;^TOF^
- ;; Tremor (characteristic hand shaking, "pill-rolling")
- ;;
- ;; __Yes __No
- ;;
- ;; Extremities affected:
- ;;
- ;; __ Right upper
- ;; ___Not affected ___Mild ___Moderate ___Severe
- ;;
- ;; __ Left upper
- ;; ___Not affected ___Mild ___Moderate ___Severe
- ;;
- ;; __ Right lower
- ;; ___Not affected ___Mild ___Moderate ___Severe
- ;;
- ;; __ Left lower
- ;; ___Not affected ___Mild ___Moderate ___Severe
- ;;
- ;; Muscle rigidity and stiffness
- ;;
- ;; __Yes __No
- ;;
- ;; Extremities affected:
- ;;
- ;; __ Right upper
- ;; ___Not affected ___Mild ___Moderate ___Severe
- ;;
- ;; __ Left upper
- ;; ___Not affected ___Mild ___Moderate ___Severe
- ;;
- ;; __ Right lower
- ;; ___Not affected ___Mild ___Moderate ___Severe
- ;;
- ;; __ Left lower
- ;; ___Not affected ___Mild ___Moderate ___Severe
- ;;
- ;; 4. Mental manifestations due to Parkinson's or its treatment
- ;;
- ;; Depression
- ;; ___None ___Mild __Moderate ___Severe
- ;;
- ;; Cognitive impairment or dementia
- ;; ___None ___Mild __Moderate ___Severe
- ;;
- ;;^TOF^
- ;; 5. Additional manifestations/complications due to Parkinson's or its
- ;; treatment
- ;;
- ;; Loss of sense of smell
- ;;
- ;; __None __Partial __Complete
- ;;
- ;; Sleep disturbance (insomnia or daytime "sleep attacks")
- ;;
- ;; ___None ___Mild __Moderate ___Severe
- ;;
- ;; Difficulty chewing/swallowing
- ;;
- ;; ___None ___Mild __Moderate ___Severe
- ;;
- ;; Urinary problems __None __Incontinence __Urinary retention
- ;;
- ;; Absorbent material required, specify pads/day:
- ;;
- ;; __0 __1 __2-4 __> 4
- ;;
- ;; Use of an appliance required?
- ;;
- ;; __Yes __No
- ;;
- ;; Constipation (due to slowing of GI tract or secondary to Parkinson's
- ;; medications)
- ;;
- ;; ___None ___Mild __Moderate ___Severe
- ;;
- ;; Sexual dysfunction
- ;;
- ;; ___None ___Mild __Moderate ___Severe (precludes intercourse)
- ;;
- ;; __Erectile dysfunction precludes intercourse
- ;;
- ;; Other manifestations/complications:_____________________________________
- ;;
- ;; 6. 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
- ;;^TOF^
- ;; 7. Functional impact
- ;;
- ;; Does the Veteran's Parkinson's disease impact his or her ability to
- ;; work?
- ;;
- ;; ___Yes ___No
- ;;
- ;; If yes, describe impact, providing one or more examples:
- ;;
- ;; __________________________________________________________________________
- ;;
- ;; 8. Remarks, if any __________________________________________________________
- ;;
- ;; __________________________________________________________________________
- ;;
- ;; Physician signature: _____________________________________ Date: ____________
- ;;
- ;; Physician printed name: __________________________________ Phone: ___________
- ;;
- ;; Medical license #: __________________
- ;;
- ;; 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[HDVBCQPD4 5224 printed Dec 13, 2024@01:47:42 Page 2
- DVBCQPD4 ;;ALB-CIOFO/ECF - PARKINSON'S QUESTIONNAIRE ; 10/6/2010
- +1 ;;2.7;AMIE;**159**;Apr 10, 1995;Build 5
- +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
- +10 ;; Parkinson's disease? ___Yes ___No
- +11 ;;
- +12 ;; ICD code: _____________________________
- +13 ;;
- +14 ;; Date of diagnosis: ____________________
- +15 ;;
- +16 ;; 2. Dominant hand
- +17 ;;
- +18 ;; ___Right ___Left ___Ambidextrous
- +19 ;;
- +20 ;; 3. Motor manifestations due to Parkinson's or its treatment
- +21 ;; (check all that apply)
- +22 ;;
- +23 ;; Stooped posture
- +24 ;; ___None ___Mild ___Moderate ___Severe
- +25 ;;
- +26 ;; Balance impairment
- +27 ;; ___None ___Mild ___Moderate ___Severe
- +28 ;;
- +29 ;; Bradykinesia or slowed motion (difficulty initiating movement, "freezing",
- +30 ;; short shuffling steps)
- +31 ;; ___None ___Mild __Moderate ___Severe
- +32 ;;
- +33 ;; Loss of automatic movements (such as blinking, leading to fixed gaze;
- +34 ;; typical Parkinson's facies)
- +35 ;; ___None ___Mild __Moderate ___Severe
- +36 ;;
- +37 ;; Speech changes (monotone, slurring words, soft or rapid speech)
- +38 ;; ___None ___Mild __Moderate ___Severe
- +39 ;;
- +40 ;;^TOF^
- +41 ;; Tremor (characteristic hand shaking, "pill-rolling")
- +42 ;;
- +43 ;; __Yes __No
- +44 ;;
- +45 ;; Extremities affected:
- +46 ;;
- +47 ;; __ Right upper
- +48 ;; ___Not affected ___Mild ___Moderate ___Severe
- +49 ;;
- +50 ;; __ Left upper
- +51 ;; ___Not affected ___Mild ___Moderate ___Severe
- +52 ;;
- +53 ;; __ Right lower
- +54 ;; ___Not affected ___Mild ___Moderate ___Severe
- +55 ;;
- +56 ;; __ Left lower
- +57 ;; ___Not affected ___Mild ___Moderate ___Severe
- +58 ;;
- +59 ;; Muscle rigidity and stiffness
- +60 ;;
- +61 ;; __Yes __No
- +62 ;;
- +63 ;; Extremities affected:
- +64 ;;
- +65 ;; __ Right upper
- +66 ;; ___Not affected ___Mild ___Moderate ___Severe
- +67 ;;
- +68 ;; __ Left upper
- +69 ;; ___Not affected ___Mild ___Moderate ___Severe
- +70 ;;
- +71 ;; __ Right lower
- +72 ;; ___Not affected ___Mild ___Moderate ___Severe
- +73 ;;
- +74 ;; __ Left lower
- +75 ;; ___Not affected ___Mild ___Moderate ___Severe
- +76 ;;
- +77 ;; 4. Mental manifestations due to Parkinson's or its treatment
- +78 ;;
- +79 ;; Depression
- +80 ;; ___None ___Mild __Moderate ___Severe
- +81 ;;
- +82 ;; Cognitive impairment or dementia
- +83 ;; ___None ___Mild __Moderate ___Severe
- +84 ;;
- +85 ;;^TOF^
- +86 ;; 5. Additional manifestations/complications due to Parkinson's or its
- +87 ;; treatment
- +88 ;;
- +89 ;; Loss of sense of smell
- +90 ;;
- +91 ;; __None __Partial __Complete
- +92 ;;
- +93 ;; Sleep disturbance (insomnia or daytime "sleep attacks")
- +94 ;;
- +95 ;; ___None ___Mild __Moderate ___Severe
- +96 ;;
- +97 ;; Difficulty chewing/swallowing
- +98 ;;
- +99 ;; ___None ___Mild __Moderate ___Severe
- +100 ;;
- +101 ;; Urinary problems __None __Incontinence __Urinary retention
- +102 ;;
- +103 ;; Absorbent material required, specify pads/day:
- +104 ;;
- +105 ;; __0 __1 __2-4 __> 4
- +106 ;;
- +107 ;; Use of an appliance required?
- +108 ;;
- +109 ;; __Yes __No
- +110 ;;
- +111 ;; Constipation (due to slowing of GI tract or secondary to Parkinson's
- +112 ;; medications)
- +113 ;;
- +114 ;; ___None ___Mild __Moderate ___Severe
- +115 ;;
- +116 ;; Sexual dysfunction
- +117 ;;
- +118 ;; ___None ___Mild __Moderate ___Severe (precludes intercourse)
- +119 ;;
- +120 ;; __Erectile dysfunction precludes intercourse
- +121 ;;
- +122 ;; Other manifestations/complications:_____________________________________
- +123 ;;
- +124 ;; 6. Financial responsibility
- +125 ;;
- +126 ;; In your judgment, is the Veteran able to manage his/her benefit payments
- +127 ;; in his/her own best interest, or able to direct someone else to
- +128 ;; do so? ___Yes ___No
- +129 ;;^TOF^
- +130 ;; 7. Functional impact
- +131 ;;
- +132 ;; Does the Veteran's Parkinson's disease impact his or her ability to
- +133 ;; work?
- +134 ;;
- +135 ;; ___Yes ___No
- +136 ;;
- +137 ;; If yes, describe impact, providing one or more examples:
- +138 ;;
- +139 ;; __________________________________________________________________________
- +140 ;;
- +141 ;; 8. Remarks, if any __________________________________________________________
- +142 ;;
- +143 ;; __________________________________________________________________________
- +144 ;;
- +145 ;; Physician signature: _____________________________________ Date: ____________
- +146 ;;
- +147 ;; Physician printed name: __________________________________ Phone: ___________
- +148 ;;
- +149 ;; Medical license #: __________________
- +150 ;;
- +151 ;; Physician address: __________________________________________________________
- +152 ;;
- +153 ;; NOTE: VA may request additional medical information, including additional
- +154 ;; examinations if necessary to complete VA's review of the Veteran's
- +155 ;; application.
- +156 ;;
- +157 ;;
- +158 ;; ^END^
- +159 QUIT