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 ---[H[J[2J[HDVBCQAR3 4031 printed Nov 22, 2024@16:55:52 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
