DVBCQAR3.m

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^

 Q

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---DVBCQAR3   4031     printed  Apr 23, 2025@18:00:09                                                                                                                                                                                                    Page 2

DVBCQAR3  ;;ALB-CIOFO/ECF - NON-DEGERATIVE ARTHRITIS QUESTIONNAIRE ; 6/15/2011

 +1       ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2

 +2       ;

TXT       ;

 +1       ;;^TOF^

 +2       ;; 9. Diagnostic testing

 +3       ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic

 +4       ;; arthritis must be confirmed by imaging studies. Once such arthritis has been

 +5       ;; documented, no further imaging studies are required by VA, even if arthritis

 +6       ;; has worsened.

 +7       ;;

 +8       ;; a. Have imaging studies been performed and are the results available?

 +9       ;; ___ Yes   ___ No

 +10      ;; If yes, indicate type of study:

 +11      ;;   ___ X-ray  Area imaged: ____________   Date: _______   Results: __________

 +12      ;;   ___ Other, specify: ______________________________________________________

 +13      ;;       Area imaged: ____________   Date: _______    Results: ________________

 +14      ;;

 +15      ;; b. Have laboratory studies been performed?

 +16      ;; NOTE: Once a diagnosis has been confirmed, laboratory studies are not

 +17      ;; indicated for a disability exam.

 +18      ;; ___ Yes   ___ No

 +19      ;; If yes, check all that apply:

 +20      ;;   ___ Erythrocyte sedimentation rate (ESR)

 +21      ;;       Date of test: ___________   Results: _________________________________

 +22      ;;   ___ C-reactive protein

 +23      ;;       Date of test: ___________  Results: __________________________________

 +24      ;;   ___ Rheumatoid factor (RF)

 +25      ;;       Date of test: ___________   Results: _________________________________

 +26      ;;   ___ Anti-DNA antibodies

 +27      ;;       Date of test: ___________   Results: _________________________________

 +28      ;;   ___ Antinuclear antibodies (ANA)

 +29      ;;       Date of test: ___________   Results: _________________________________

 +30      ;;   ___ Anti-cyclic citrullinated peptide (anti-CCP) antibodies

 +31      ;;       Date of test: ___________   Results: _________________________________

 +32      ;;   ___ CBC  Date of test: ___________

 +33      ;;       Hemoglobin: ______      Hematocrit: _______

 +34      ;;       White blood cell count: ______   Platelets: __________________________

 +35      ;;   ___ Uric Acid Test  Date of test: ___________  Results: _________________

 +36      ;;   ___ Other, specify: ______________________________________________________

 +37      ;;       Date of test: ___________   Results: _________________________________

 +38      ;;

 +39      ;; c. Has the Veteran had a joint aspiration/synovial fluid analysis?

 +40      ;; NOTE: Once a diagnosis has been confirmed, testing is not indicated for a

 +41      ;; disability exam.

 +42      ;; ___ Yes   ___ No

 +43      ;; If yes, indicate joint aspirated, date and results: _______________________

 +44      ;;^TOF^

 +45      ;; d. Has the Veteran had a biopsy (e.g., skin, nerve, fat, rectum, kidney)?

 +46      ;; NOTE: Once a diagnosis has been confirmed, testing is not indicated for a

 +47      ;; disability exam.

 +48      ;; ___ Yes   ___ No

 +49      ;; If yes, indicate area biopsied, date and results: __________________________

 +50      ;;

 +51      ;; e. Are there any other significant diagnostic test findings and/or results?

 +52      ;; ___ Yes   ___ No

 +53      ;; If yes, provide type of test or procedure, date and results (brief summary):

 +54      ;; ____________________________________________________________________________

 +55      ;;

 +56      ;; 10. Functional impact

 +57      ;; Does the Veteran's inflammatory, autoimmune, crystalline or infectious

 +58      ;; arthritis condition or dysbaric osteonecrosis impact his or her ability

 +59      ;; to work?

 +60      ;; ___ Yes   ___ No

 +61      ;; If yes describe the impact of each of the Veteran's arthritis or

 +62      ;; osteonecrosis conditions, providing one or more examples:

 +63      ;;

 +64      ;; 11. Remarks, if any: _______________________________________________________

 +65      ;; 

 +66      ;; Physician signature: ____________________________________ Date: ____________

 +67      ;;

 +68      ;; Physician printed name: _________________________________ Phone: ___________

 +69      ;;

 +70      ;; Medical license #: ______________________________________ Fax: _____________

 +71      ;;

 +72      ;; Physician address: _________________________________________________________

 +73      ;;

 +74      ;; NOTE: VA may request additional medical information, including additional

 +75      ;; examinations if necessary to complete VA's review of the Veteran's

 +76      ;; application.

 +77      ;;

 +78      ;;^END^

 +79       QUIT