©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
DVBCQAR3 ;;ALB-CIOFO/ECF - NON-DEGERATIVE ARTHRITIS QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
;
TXT ;
;;^TOF^
;; 9. Diagnostic testing
;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
;; arthritis must be confirmed by imaging studies. Once such arthritis has been
;; documented, no further imaging studies are required by VA, even if arthritis
;; has worsened.
;;
;; a. Have imaging studies been performed and are the results available?
;; ___ Yes ___ No
;; If yes, indicate type of study:
;; ___ X-ray Area imaged: ____________ Date: _______ Results: __________
;; ___ Other, specify: ______________________________________________________
;; Area imaged: ____________ Date: _______ Results: ________________
;;
;; b. Have laboratory studies been performed?
;; NOTE: Once a diagnosis has been confirmed, laboratory studies are not
;; indicated for a disability exam.
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Erythrocyte sedimentation rate (ESR)
;; Date of test: ___________ Results: _________________________________
;; ___ C-reactive protein
;; Date of test: ___________ Results: __________________________________
;; ___ Rheumatoid factor (RF)
;; Date of test: ___________ Results: _________________________________
;; ___ Anti-DNA antibodies
;; Date of test: ___________ Results: _________________________________
;; ___ Antinuclear antibodies (ANA)
;; Date of test: ___________ Results: _________________________________
;; ___ Anti-cyclic citrullinated peptide (anti-CCP) antibodies
;; Date of test: ___________ Results: _________________________________
;; ___ CBC Date of test: ___________
;; Hemoglobin: ______ Hematocrit: _______
;; White blood cell count: ______ Platelets: __________________________
;; ___ Uric Acid Test Date of test: ___________ Results: _________________
;; ___ Other, specify: ______________________________________________________
;; Date of test: ___________ Results: _________________________________
;;
;; c. Has the Veteran had a joint aspiration/synovial fluid analysis?
;; NOTE: Once a diagnosis has been confirmed, testing is not indicated for a
;; disability exam.
;; ___ Yes ___ No
;; If yes, indicate joint aspirated, date and results: _______________________
;;^TOF^
;; d. Has the Veteran had a biopsy (e.g., skin, nerve, fat, rectum, kidney)?
;; NOTE: Once a diagnosis has been confirmed, testing is not indicated for a
;; disability exam.
;; ___ Yes ___ No
;; If yes, indicate area biopsied, date and results: __________________________
;;
;; e. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;
;; 10. Functional impact
;; Does the Veteran's inflammatory, autoimmune, crystalline or infectious
;; arthritis condition or dysbaric osteonecrosis impact his or her ability
;; to work?
;; ___ Yes ___ No
;; If yes describe the impact of each of the Veteran's arthritis or
;; osteonecrosis conditions, providing one or more examples:
;;
;; 11. Remarks, if any: _______________________________________________________
;;
;; Physician signature: ____________________________________ Date: ____________
;;
;; Physician printed name: _________________________________ Phone: ___________
;;
;; Medical license #: ______________________________________ Fax: _____________
;;
;; 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^
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