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1DVBCWME3 ;BP-CIOFO/MM -MENTAL DISORDERS (EXCEPT PTSD & EATING DISORDERS);3/26/2002
2 ;;2.7;AMIE;**43**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Medical History (Subjective Complaints):
9 ;; Comment on:
10 ;;
11 ;; 1. Past Medical History:
12 ;;
13 ;; a. Previous hospitalizations and outpatient care.
14 ;; b. Medical and occupational history from the time between last rating
15 ;; examination and the present, UNLESS the purpose of this examination
16 ;; is to ESTABLISH service connection, then the complete medical history
17 ;; since discharge from military service is required.
18 ;;
19 ;; 2. Present Medical, Occupational, and Social History -
20 ;; over the past one year.
21 ;;
22 ;; a. Frequency, severity, and duration of psychiatric symptoms.
23 ;; b. Length of remissions, to include capacity for adjustment during
24 ;; periods of remissions.
25 ;; c. Extent of time lost from work over the past 12 month period and
26 ;; social impairment. If employed, identify current occupation and
27 ;; length of time at this job. If unemployed, note in Complaints whether
28 ;; veteran contends it is due to the effects of a mental disorder.
29 ;; Further indicate following DIAGNOSIS what factors, and objective
30 ;; findings support or rebut that contention.
31 ;; d. Treatments including statement on effectiveness and side effects
32 ;; experienced.
33 ;;
34 ;; 3. Subjective Complaints:
35 ;;
36 ;; a. Describe fully.
37 ;;
38 ;;C. Examination (Objective Findings):
39 ;; Address each of the following and fully describe:
40 ;;
41 ;; 1. Mental status exam to confirm or establish diagnosis in
42 ;; accordance with DSM-IV.
43 ;; 2. Additionally, to allow evaluation by the rating specialist, describe
44 ;; and fully explain the existence, frequency, and extent of the following
45 ;; signs and symptoms, or any others present, and relate how they interfere
46 ;; with employment and social functioning:
47 ;; a. Impairment of thought process or communication.
48 ;; b. Delusions, hallucinations and their persistence.
49 ;; c. Inappropriate behavior cited with examples.
50 ;; d. Suicidal or homicidal thoughts, ideations or plans or intent.
51 ;; e. Ability to maintain minimal personal hygiene and other basic
52 ;; activities of daily living.
53 ;; f. Orientation to person, place and time.
54 ;; g. Memory loss or impairment (both short and/or long term).
55 ;; h. Obsessive or ritualistic behavior which interferes with routine
56 ;; activities (describe with examples).
57 ;; i. Rate and flow of speech and note irrelevant, illogical, or obscure
58 ;; speech patterns and whether constant or intermittent.
59 ;; j. Panic attacks noting the severity, duration, frequency and effect
60 ;; on independent functioning and whether clinically observed or good
61 ;; evidence of prior clinical or equivalent observation.
62 ;; k. Depression, depressed mood, or anxiety.
63 ;; l. Impaired impulse control and its effect on motivation or mood.
64 ;; m. Sleep impairment and describe extent it interferes with daytime
65 ;; activities.
66 ;; n. Other symptoms and the extent to which they interfere with
67 ;; activities.
68 ;;
69 ;;D. Diagnostic Tests:
70 ;;
71 ;; 1. Provide psychological testing if deemed necessary.
72 ;; 2. If testing is requested, the results must be reported and considered in
73 ;; arriving at the diagnosis.
74 ;; 3. Provide any specific evaluation information required by the rating board
75 ;; or on BVA Remand (in claims folder).
76 ;;
77 ;; a. COMPETENCY: State whether the veteran is capable of managing
78 ;; his/her benefit payments in the individual's own best interests
79 ;; (a physical disability which prevents the veteran from attending
80 ;; to financial matters in person is not a proper basis for a finding
81 ;; of incompetency unless the veteran is, by reason of that
82 ;; disability, incapable of directing someone else in handling
83 ;; the individual's financial affairs).
84 ;;
85 ;; b. OTHER OPINION: Furnish any other specific opinion requested
86 ;; by the rating board or BVA Remand furnishing the complete
87 ;; rationale and citation of medical texts or treatise supporting
88 ;; opinion, if medical literature review was undertaken.
89 ;; If the requested opinion is medically not ascertainable on exam
90 ;; or testing, please indicate WHY. If the requested opinion can not
91 ;; be expressed without resorting to speculation or making improbable
92 ;; assumptions say so, and explain why. If the opinion asks "...is it
93 ;; at least as likely as not..?", fully explain the clinical findings
94 ;; and rationale for the opinion.
95 ;; 4. Include results of all diagnostic and clinical tests conducted
96 ;; in the examination report.
97 ;;TOF
98 ;;E. Diagnosis:
99 ;; Provide:
100 ;;
101 ;; 1. The Diagnosis must conform to DSM-IV and be supported by the findings
102 ;; on the examination report.
103 ;; 2. If the diagnosis is changed, explain fully whether the new diagnosis
104 ;; represents a progression of the prior diagnosis or development of a new
105 ;; and separate condition.
106 ;; 3. If there are multiple mental disorders, delineate to the extent possible
107 ;; the symptoms associated with each and a discussion of relationship.
108 ;; 4. Evaluation is based on the effects of the signs and symptoms on
109 ;; occupational and social functioning.
110 ;;
111 ;;NOTE: VA is prohibited by statute, 38 U.S.C. 1110, from paying compensation
112 ;;for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE.
113 ;;However, when a veteran's alcohol or drug abuse disability is secondary to
114 ;;or is caused or aggravated by a primary service-connected disorder, the
115 ;;veteran may be entitled to compensation. See Allen v. Principi, 237 F.3d
116 ;;1368, 1381 (Fed. Cir. 2001). Therefore, it is important to determine the
117 ;;relationship, if any, between a service-connected disorder and a disability
118 ;;resulting from the veteran's alcohol or drug abuse. Unless alcohol or drug
119 ;;abuse is secondary to or is caused or aggravated by another mental disorder,
120 ;;you should separate, to the extent possible, the effects of the alcohol or
121 ;;drug abuse from the effects of the other mental disorder(s). If it is not
122 ;;possible to separate the effects in such cases, please explain why.
123 ;;
124 ;;F. Global Assessment of Functioning (GAF):
125 ;;
126 ;;NOTE: The complete multi-axial format as specified by DSM-IV may be required
127 ;;by BVA REMAND or specifically requested by the rating specialist. If so,
128 ;;include the GAF score and note whether it refers to current functioning.
129 ;;A BVA REMAND may also request, in addition to an overall GAF score, that a
130 ;;separate GAF score be provided for each mental disorder present when there are
131 ;;multiple Axis I or Axis II diagnoses and not all are service-connected.
132 ;;If separate GAF scores can be given, an explanation and discussion of
133 ;;the rationale is needed. If it is not possible, an explanation as to why not is
134 ;;needed. (See the above note pertaining to alcohol or drug abuse.)
135 ;;
136 ;;
137 ;;Signature: Date:
138 ;;END
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