©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
DVBCEXM1 ;ALB/CMC REQUEST WORKSHEET TEXT ; 8/15/97
;;2.7;AMIE;**12,16,80**;Apr 10, 1995
;
TXT ;
;; Body System: Musculoskeletal (DC Series 5000, 5100, 5200, 5300)
;; ( ) Bones (Fractures and Bone Disease) ( ) Fibromyalgia
;; ( ) Amputation, Residuals of ( ) Joints (Shoulder/Elbow/Wrist/Hip/Knee/Ankle)
;; ( ) Hand, Thumb, and Fingers ( ) Feet
;; ( ) Spine (Cervical, Thoracic & Lumbar) ( ) Muscles
;;
;; Body System: Organs of Sense (DC Series 6000, 6100, 6200)
;; ( ) Eye Examination ( ) Audio
;; ( ) Ear Disease ( ) Sense of Smell and Taste
;;
;; Body System: Infectious/Immune/Nutritional (DC Series 6300)
;; ( ) Infectious, Immune, and Nutritional Disabilities
;; ( ) HIV-Related Illness ( ) Chronic Fatigue Syndrome
;;
;; Body System: Respiratory (DC Series 6500, 6600, 6700, 6800)
;; ( ) Nose, Sinus, Larynx, and Pharynx ( ) Respiratory (Obstructive, Restrictive,
;; ( ) Pulmonary Tuberculosis and and Interstitial)
;; Mycobacterial Diseases ( ) Respiratory Diseases, Miscellaneous
;;
;; Body System: Cardiovascular (DC Series 7000, 7100)
;; ( ) Arrhythmias ( ) Heart
;; ( ) Arteries, Veins and Miscellaneous ( ) Hypertension
;;
;; Body System: Digestive (DC Series 7200, 7300)
;; ( ) Mouth, Lips, and Tongue ( ) Esophagus and Hiatal Hernia
;; ( ) Intestines (Large and Small) ( ) Liver, Gall Bladder, and Pancreas
;; ( ) Digestive Conditions, Miscellaneous ( ) Rectum and Anus
;; ( ) Stomach, Duodenum, and Peritoneal Adhesions
;;
;; Body System: Genitourinary (DC Series 7500)
;; ( ) Genitourinary Examination
;;
;; Body System: Gynecological and Breast (DC Series 7600)
;; ( ) Gynecological Conditions and
;; Disorders of the Breast
;;
;; Body System: Hemic and Lymphatic (DC Series 7700)
;; ( ) Hemic Disorders ( ) Lymphatic Disorders
;;
;; Body System: Skin (DC Series 7800)
;; ( ) Scars ( ) Skin Diseases (other than scars)
;;
;; Body System: Endocrine (DC Series 7900)
;; ( ) Endocrine Diseases, Miscellaneous ( ) Thyroid and Parathyroid Diseases
;; ( ) Cushing's Syndrome ( ) Acromegaly
;; ( ) Diabetes Mellitus
;;
;; Body System: Neurologic (DC Series 8000, 8100, 8200, 8300, 8400, 8500, 8600, 8700, 8800, 8900)
;; ( ) Brain and Spinal Cord ( ) Cranial Nerves
;; ( ) Neurological Disorders, Miscellaneous ( ) Peripheral Nerves
;; ( ) Epilepsy and Narcolepsy
;;
;; Body System: Mental Disorders (DC Series 9200, 9300, 9400, 9500)
;; ( ) Mental Disorders (not PTSD and Eating Disorders)
;; ( ) Initial Evaluation for Post-Traumatic Stress Disorder (PTSD)
;; ( ) Review Examination for Post-Traumatic Stress Disorder (PTSD)
;; ( ) Eating Disorders (Mental Disorders)
;;
;; Body System: Dental and Oral (DC Series 9900)
;; ( ) Dental and Oral
;;
;; Special Examinations:
;; ( ) Aid and Attendance or Housebound Examination
;; ( ) Prisoner of War Protocol Examination
;; ( ) Cold Injury Protocol Examination
;; ( ) Gulf War Guidelines
;; ( ) Social and Industrial Survey
;;END