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 Apr 09, 2024@20:55:55 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
