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
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCEXM1 4158 printed Oct 16, 2024@17:44:56 Page 2
DVBCEXM1 ;ALB/CMC REQUEST WORKSHEET TEXT ; 8/15/97
+1 ;;2.7;AMIE;**12,16,80**;Apr 10, 1995
+2 ;
TXT ;
+1 ;; Body System: Musculoskeletal (DC Series 5000, 5100, 5200, 5300)
+2 ;; ( ) Bones (Fractures and Bone Disease) ( ) Fibromyalgia
+3 ;; ( ) Amputation, Residuals of ( ) Joints (Shoulder/Elbow/Wrist/Hip/Knee/Ankle)
+4 ;; ( ) Hand, Thumb, and Fingers ( ) Feet
+5 ;; ( ) Spine (Cervical, Thoracic & Lumbar) ( ) Muscles
+6 ;;
+7 ;; Body System: Organs of Sense (DC Series 6000, 6100, 6200)
+8 ;; ( ) Eye Examination ( ) Audio
+9 ;; ( ) Ear Disease ( ) Sense of Smell and Taste
+10 ;;
+11 ;; Body System: Infectious/Immune/Nutritional (DC Series 6300)
+12 ;; ( ) Infectious, Immune, and Nutritional Disabilities
+13 ;; ( ) HIV-Related Illness ( ) Chronic Fatigue Syndrome
+14 ;;
+15 ;; Body System: Respiratory (DC Series 6500, 6600, 6700, 6800)
+16 ;; ( ) Nose, Sinus, Larynx, and Pharynx ( ) Respiratory (Obstructive, Restrictive,
+17 ;; ( ) Pulmonary Tuberculosis and and Interstitial)
+18 ;; Mycobacterial Diseases ( ) Respiratory Diseases, Miscellaneous
+19 ;;
+20 ;; Body System: Cardiovascular (DC Series 7000, 7100)
+21 ;; ( ) Arrhythmias ( ) Heart
+22 ;; ( ) Arteries, Veins and Miscellaneous ( ) Hypertension
+23 ;;
+24 ;; Body System: Digestive (DC Series 7200, 7300)
+25 ;; ( ) Mouth, Lips, and Tongue ( ) Esophagus and Hiatal Hernia
+26 ;; ( ) Intestines (Large and Small) ( ) Liver, Gall Bladder, and Pancreas
+27 ;; ( ) Digestive Conditions, Miscellaneous ( ) Rectum and Anus
+28 ;; ( ) Stomach, Duodenum, and Peritoneal Adhesions
+29 ;;
+30 ;; Body System: Genitourinary (DC Series 7500)
+31 ;; ( ) Genitourinary Examination
+32 ;;
+33 ;; Body System: Gynecological and Breast (DC Series 7600)
+34 ;; ( ) Gynecological Conditions and
+35 ;; Disorders of the Breast
+36 ;;
+37 ;; Body System: Hemic and Lymphatic (DC Series 7700)
+38 ;; ( ) Hemic Disorders ( ) Lymphatic Disorders
+39 ;;
+40 ;; Body System: Skin (DC Series 7800)
+41 ;; ( ) Scars ( ) Skin Diseases (other than scars)
+42 ;;
+43 ;; Body System: Endocrine (DC Series 7900)
+44 ;; ( ) Endocrine Diseases, Miscellaneous ( ) Thyroid and Parathyroid Diseases
+45 ;; ( ) Cushing's Syndrome ( ) Acromegaly
+46 ;; ( ) Diabetes Mellitus
+47 ;;
+48 ;; Body System: Neurologic (DC Series 8000, 8100, 8200, 8300, 8400, 8500, 8600, 8700, 8800, 8900)
+49 ;; ( ) Brain and Spinal Cord ( ) Cranial Nerves
+50 ;; ( ) Neurological Disorders, Miscellaneous ( ) Peripheral Nerves
+51 ;; ( ) Epilepsy and Narcolepsy
+52 ;;
+53 ;; Body System: Mental Disorders (DC Series 9200, 9300, 9400, 9500)
+54 ;; ( ) Mental Disorders (not PTSD and Eating Disorders)
+55 ;; ( ) Initial Evaluation for Post-Traumatic Stress Disorder (PTSD)
+56 ;; ( ) Review Examination for Post-Traumatic Stress Disorder (PTSD)
+57 ;; ( ) Eating Disorders (Mental Disorders)
+58 ;;
+59 ;; Body System: Dental and Oral (DC Series 9900)
+60 ;; ( ) Dental and Oral
+61 ;;
+62 ;; Special Examinations:
+63 ;; ( ) Aid and Attendance or Housebound Examination
+64 ;; ( ) Prisoner of War Protocol Examination
+65 ;; ( ) Cold Injury Protocol Examination
+66 ;; ( ) Gulf War Guidelines
+67 ;; ( ) Social and Industrial Survey
+68 ;;END
