DVBCAOCK ;ALB/GTS-557/THM-AGENT ORANGE/RESIDUALS OF DIOXIN ; 5/21/91 9:56 AM
;;2.7;AMIE;;Apr 10, 1995
;
S PG=1,HD91="Department of Veterans Affairs",HD9="Full Exam Worksheet"
EN D:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
W !?25,HD91,!?22,"Compensation and Pension Examination",! W ?33,"# 1710 Worksheet" S HD7="RESIDUALS OF DIOXIN EXPOSURE (AGENT ORANGE)",HD8="For "_HD7 W !?(40-($L(HD9)\2)),HD9,!?(40-($L(HD8)\2)),HD8,!!
W !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,!,"Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
W !!!!,"Narrative: "
S LNS="__________",LX="TXT" F I=1:1 S LY=$T(@LX+I) Q:LY["$END" W ?13,$P(LY,";;",2),!
W !!,"A. Initial data base for possible exposure to toxic chemicals:",!!,"Branch of service: ",LNS,?33,"Service serial number: ",LNS,!!
S X="month/year",Y="from __________ to __________" W "Dates of service:",!?26,X,?40,X,!!,"Last period: ",?21,Y,!!?26,X,?40,X,!!,"Next to last period: ",Y,!!
W "Date of birth: __________",!!,"Marital status: ___ married ___ divorced ___ separated",!!!
W "Did veteran have military service in Vietnam? ___ Yes ___ No",!!,"If yes, list all tours of duty in Vietnam:",!!?7,X,?35,X,!,"From:",?30,"To:",! D HD2
W "Indicate the Corps or area where veteran served in Vietnam:",!!,"I Corps ___ II Corps ___ III Corps ___ IV Corps ___ Sea duty ___",!!,"More than one ___ Don't know ___ Other (specify)",LNS,!!
W "List military units in which veteran served (specify complete",!,"unabbreviated titles such as company, battalion, etc.):",!!!!!
W "B. Veteran's exposure to Agent Orange (indicate one category for",!?5,"each circumstance):",!!?36,"Definitely Probably Not Definitely",!?39,"yes",?50,"yes",?58,"sure",?69,"no",!!
W ?3,"1. Veteran was involved in",!?3,"handling or spraying A.O.",!!?3,"2. Veteran was not directly",!?3,"sprayed but was in a recently",!?3,"sprayed area.",!!
W ?3,"3. Veteran was exposed to",!?3,"herbicides other than A.O.",!!?3,"4. Veteran was directly",!?3,"sprayed with Agent Orange.",!!?3,"5. Veteran ate food or drink",!?3,"that could have been contaminated.",!!!
W !!,"C. Indicate how many exposures the veteran alleges:",!!!,"D. Indicate the nature of each exposure:",! D HD2
W "E. Medical history (include symptoms at time of exposure or",!?4,"later attributed by veteran to exposure):",!!!!!!!,"F. Subjective complaints:",!!!!!!!,"G. Objective findings:",!!
W ?2,"a. Height _____ weight _____ pulse _____ blood pressure _______",!! G ^DVBCAOC1
;
HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for ",HD7,!,"for ",NAME,!!!
Q
;
SETIOF ; ** Set device control var's
D HOME^%ZIS
Q
;
TXT ;
;;Chloracne or other acneform disease consistant with
;;chloracne, non-Hodgkins lymphoma, and soft-tissue
;;sarcomas are presumtive Agent Orange-related
;;disabilities. Veterans who served in Vietnam and
;;in the waters offshore are presumed to have been
;;exposed to Agent Orange and/or other herbicides
;;which may contain dioxin. Attention should be paid
;;to examination of the skin, nervous system, muscular
;;function, liver, kidneys, lymphatic system and mental
;;status. Questioning should attempt to uncover details
;;of exposure and any adverse affects.
;;$END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCAOCK 3322 printed Nov 22, 2024@16:53:46 Page 2
DVBCAOCK ;ALB/GTS-557/THM-AGENT ORANGE/RESIDUALS OF DIOXIN ; 5/21/91 9:56 AM
+1 ;;2.7;AMIE;;Apr 10, 1995
+2 ;
+3 SET PG=1
SET HD91="Department of Veterans Affairs"
SET HD9="Full Exam Worksheet"
EN if '$DATA(IOF)
DO SETIOF
if (IOST?1"C-".E)
WRITE @IOF
+1 WRITE !?25,HD91,!?22,"Compensation and Pension Examination",!
WRITE ?33,"# 1710 Worksheet"
SET HD7="RESIDUALS OF DIOXIN EXPOSURE (AGENT ORANGE)"
SET HD8="For "_HD7
WRITE !?(40-($LENGTH(HD9)\2)),HD9,!?(40-($LENGTH(HD8)\2)),HD8,!!
+2 WRITE !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,!,"Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
+3 WRITE !!!!,"Narrative: "
+4 SET LNS="__________"
SET LX="TXT"
FOR I=1:1
SET LY=$TEXT(@LX+I)
if LY["$END"
QUIT
WRITE ?13,$PIECE(LY,";;",2),!
+5 WRITE !!,"A. Initial data base for possible exposure to toxic chemicals:",!!,"Branch of service: ",LNS,?33,"Service serial number: ",LNS,!!
+6 SET X="month/year"
SET Y="from __________ to __________"
WRITE "Dates of service:",!?26,X,?40,X,!!,"Last period: ",?21,Y,!!?26,X,?40,X,!!,"Next to last period: ",Y,!!
+7 WRITE "Date of birth: __________",!!,"Marital status: ___ married ___ divorced ___ separated",!!!
+8 WRITE "Did veteran have military service in Vietnam? ___ Yes ___ No",!!,"If yes, list all tours of duty in Vietnam:",!!?7,X,?35,X,!,"From:",?30,"To:",!
DO HD2
+9 WRITE "Indicate the Corps or area where veteran served in Vietnam:",!!,"I Corps ___ II Corps ___ III Corps ___ IV Corps ___ Sea duty ___",!!,"More than one ___ Don't know ___ Other (specify)",LNS,!!
+10 WRITE "List military units in which veteran served (specify complete",!,"unabbreviated titles such as company, battalion, etc.):",!!!!!
+11 WRITE "B. Veteran's exposure to Agent Orange (indicate one category for",!?5,"each circumstance):",!!?36,"Definitely Probably Not Definitely",!?39,"yes",?50,"yes",?58,"sure",?69,"no",!!
+12 WRITE ?3,"1. Veteran was involved in",!?3,"handling or spraying A.O.",!!?3,"2. Veteran was not directly",!?3,"sprayed but was in a recently",!?3,"sprayed area.",!!
+13 WRITE ?3,"3. Veteran was exposed to",!?3,"herbicides other than A.O.",!!?3,"4. Veteran was directly",!?3,"sprayed with Agent Orange.",!!?3,"5. Veteran ate food or drink",!?3,"that could have been contaminated.",!!!
+14 WRITE !!,"C. Indicate how many exposures the veteran alleges:",!!!,"D. Indicate the nature of each exposure:",!
DO HD2
+15 WRITE "E. Medical history (include symptoms at time of exposure or",!?4,"later attributed by veteran to exposure):",!!!!!!!,"F. Subjective complaints:",!!!!!!!,"G. Objective findings:",!!
+16 WRITE ?2,"a. Height _____ weight _____ pulse _____ blood pressure _______",!!
GOTO ^DVBCAOC1
+17 ;
HD2 SET PG=PG+1
WRITE @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for ",HD7,!,"for ",NAME,!!!
+1 QUIT
+2 ;
SETIOF ; ** Set device control var's
+1 DO HOME^%ZIS
+2 QUIT
+3 ;
TXT ;
+1 ;;Chloracne or other acneform disease consistant with
+2 ;;chloracne, non-Hodgkins lymphoma, and soft-tissue
+3 ;;sarcomas are presumtive Agent Orange-related
+4 ;;disabilities. Veterans who served in Vietnam and
+5 ;;in the waters offshore are presumed to have been
+6 ;;exposed to Agent Orange and/or other herbicides
+7 ;;which may contain dioxin. Attention should be paid
+8 ;;to examination of the skin, nervous system, muscular
+9 ;;function, liver, kidneys, lymphatic system and mental
+10 ;;status. Questioning should attempt to uncover details
+11 ;;of exposure and any adverse affects.
+12 ;;$END
