DVBCQAV2 ;;ALB-CIOFO/ECF,SBW - ARTERIES AND VEINS QUESTIONNAIRE ; 20/JUNE/2011
;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
;
TXT ;
;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
;; disability benefits. VA will consider the information you provide on this
;; questionnaire as part of their evaluation in processing the Veteran's claim.
;;
;; 1. Diagnosis
;; Does the Veteran now have or has he/she ever had a vascular disease
;; (arterial or venous)?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to vascular conditions:
;; Diagnosis #1: ___________________
;; ICD code(s): ___________________
;; Date of diagnosis: ______________
;;
;; Diagnosis #2: ___________________
;; ICD code(s): ___________________
;; Date of diagnosis: ______________
;;
;; Diagnosis #3: ___________________
;; ICD code(s): ___________________
;; Date of diagnosis: ______________
;;
;; If there are additional diagnoses that pertain to vascular diseases,
;; list using above format: ____________________________________________________
;;
;; 2. Medical history
;; a. Describe the cause/onset of the Veteran's current vascular condition(s)
;; (brief summary): ____________________________________________________________
;;
;; b. Type of vascular disease condition: (Check all that apply)
;; ___ Section I: Varicose veins and/or post-phlebitic syndrome
;; ___ Section II: Peripheral vascular disease, aneurysm of any large
;; artery (other than aorta), arteriosclerosis obliterans or
;; thrombo-angiitis obliterans (Buerger's Disease)
;; ___ Section III: Aortic aneurysm
;; ___ Section IV: Aneurysm of a small artery
;; ___ Section V: Raynaud's syndrome
;; ___ Section VI: Arteriovenous (AV) fistula, angioneurotic edema or
;; erythromelalgia
;; If checked, complete appropriate Section I-VI.
;; Regardless of checked condition, complete Section VII.
;;^TOF^
;; Section I: Varicose veins and/or post-phlebitic syndrome
;;
;; Does the Veteran have varicose veins or post-phlebitic syndrome of any
;; etiology?
;; ___ Yes ___ No
;;
;; If yes, check all symptoms that apply and indicate extremity affected:
;; ___ Asymptomatic palpable varicose veins __ Right __ Left __ Both
;; ___ Asymptomatic visible varicose veins __ Right __ Left __ Both
;; ___ Aching and fatigue in leg after
;; prolonged standing or walking __ Right __ Left __ Both
;; ___ Symptoms relieved by elevation of
;; extremity __ Right __ Left __ Both
;; ___ Symptoms relieved by compression hosiery __ Right __ Left __ Both
;;
;; If yes, check all findings and/or signs that apply and indicate extremity
;; affected:
;; ___ Incipient stasis pigmentation or eczema __ Right __ Left __ Both
;; ___ Persistent stasis pigmentation or eczema __ Right __ Left __ Both
;; ___ Intermittent ulceration __ Right __ Left __ Both
;; ___ Intermittent edema of extremity __ Right __ Left __ Both
;; ___ Persistent edema that is incompletely
;; relieved by elevation of extremity __ Right __ Left __ Both
;; ___ Persistent edema __ Right __ Left __ Both
;; ___ Persistent subcutaneous induration __ Right __ Left __ Both
;; ___ Massive board-like edema __ Right __ Left __ Both
;; ___ Constant pain at rest __ Right __ Left __ Both
;;
;; Section II: Peripheral vascular disease, aneurysm of any large artery
;; (other than aorta), arteriosclerosis obliterans or thrombo-angiitis
;; obliterans (Buerger's Disease)
;;
;; a. Has the Veteran ever been diagnosed with: (check all that apply)?
;; ___ Peripheral vascular disease
;; ___ Aneurysm of any large artery (other than aorta)
;; ___ Arteriosclerosis obliterans
;; ___ Thrombo-angiitis obliterans (Buerger's Disease)
;; ___ None of the above
;; If any of the above conditions are checked, answer questions b-f.
;;
;; b. Has the Veteran undergone surgery for any of these listed conditions?
;; ___ Yes ___ No
;; If yes, type of surgery: ___________________ Date: ____________
;;
;; c. Has the Veteran undergone any procedure (other than surgery) for
;; revascularization?
;; ___ Yes ___ No
;; If yes, type of procedure: ___________________ Date: __________
;;^TOF^
;; d. Indicate severity of current signs and symptoms and indicate extremity
;; affected: (check all that apply):
;; ___ Claudication on walking more than 100
;; yards __ Right __ Left __ Both
;; ___ Claudication on walking between 25 and 100
;; yards on a level grade at 2 miles per hour __ Right __ Left __ Both
;; ___ Claudication on walking less than 25 yards
;; on a level grade at 2 miles per hour __ Right __ Left __ Both
;; ___ Persistent coldness of the extremity __ Right __ Left __ Both
;; ___ Diminished peripheral pulses __ Right __ Left __ Both
;; ___ Ischemic limb pain at rest __ Right __ Left __ Both
;; ___ Trophic changes (thin skin, absence of
;; hair, dystrophic nails) __ Right __ Left __ Both
;; ___ 1 or more deep ischemic ulcers __ Right __ Left __ Both
;;
;; Section III: Aortic aneurysm
;;
;; a. Has the Veteran ever been diagnosed with an aortic aneurysm?
;; ___ Yes ___ No
;; If yes, has the Veteran had a surgical procedure for an aortic aneurysm?
;; ___ Yes ___ No
;; If yes, indicate type of surgery: _____________________ Date: __________
;;
;; b. Does the Veteran currently have an aortic aneurysm?
;; ___ Yes ___ No
;; If yes, indicate severity:
;; 5 centimeters or larger in diameter: ___ Yes ___ No
;; Symptomatic ___ Yes ___ No
;; Precludes exertion ___ Yes ___ No
;;
;; c. Does the Veteran have any post-surgical residuals due to treatment for
;; aortic aneurysm?
;; ___ Yes ___ No
;; If yes, describe: _______________________________________________________
;; (If there are symptoms or post-surgical residuals, also complete
;; appropriate Questionnaire according to body system affected.)
;;
;; Section IV: Aneurysm of a small artery
;;
;; a. Has the Veteran been diagnosed with an aneurysm of a small artery?
;; ___ Yes ___ No
;; If yes, has the Veteran had a surgical procedure for an aneurysm of a small
;; artery?
;; ___ Yes ___ No
;; If yes, indicate type of surgery: ______________________ Date: __________
;;^TOF^
;; b. Does the Veteran currently have an aneurysm of a small artery?
;; ___ Yes ___ No
;; If yes, is the condition symptomatic?
;; ___ Yes ___ No
;; If yes, describe: ________________________________________________________
;; Also, complete appropriate Questionnaire according to body system
;; affected.
;;
;; c. Does the Veteran have any post-surgical residuals due to treatment for
;; an aneurysm of a small artery?
;; ___ Yes ___ No
;; If yes, describe: ________________________________________________________
;; Also, complete appropriate Questionnaire according to body system
;; affected.
;;
;; Section V: Raynaud's syndrome
;;
;; a. Does the Veteran have Raynaud's syndrome?
;; ___ Yes ___ No
;; If yes, complete this section.
;;
;; b. Does the Veteran have characteristic attacks?
;; ___ Yes ___ No
;; If yes, indicate frequency of characteristic attacks:
;; ___ Less than once a week
;; ___ 1 to 3 times a week
;; ___ 4 to 6 times a week
;; ___ At least daily
;; NOTE: Characteristic attacks consist of sequential color changes of the digits
;; of one or more extremities lasting minutes to hours, sometimes with pain and
;; paresthesias, and precipitated by exposure to cold or by emotional upsets.
;;
;; c. Does the Veteran have 2 or more digital ulcers?
;; ___ Yes ___ No
;;
;; d. Does the Veteran have autoamputation of one or more digits?
;; ___ Yes ___ No
;;
;; Section VI: Arteriovenous (AV) fistula, angioneurotic edema or
;; erythromelalgia
;;
;; a. Does the Veteran have arteriovenous (AV) fistula, angioneurotic edema or
;; erythromelalgia?
;; ___ Yes ___ No
;; If yes, complete this section.
;;^TOF^
;; b. Does the Veteran have a traumatic arteriovenous (AV) fistula?
;; ___ Yes ___ No
;; If yes, complete the following:
;; 1. Indicate site of traumatic AV fistula:
;; ___ Right upper extremity ___ Right lower extremity
;; ___ Left upper extremity ___ Left lower extremity
;; ___ Other location, specify ________________
;; 2. Indicate findings:
;; ___ Edema
;; ___ Stasis dermatitis
;; ___ Ulceration
;; ___ Cellulitis
;; ___ Enlarged heart
;; ___ Wide pulse pressure
;; ___ Tachycardia
;; ___ High output heart failure
;; 3. Is there more than one traumatic AV fistula?
;; ___ Yes ___ No
;; If yes, provide location and findings for each:________________________
;;
;; c. Does the Veteran have angioneurotic edema?
;; ___ Yes ___ No
;; If yes, indicate severity and frequency of characteristic attacks:
;; ___ Without laryngeal involvement
;; ___ With laryngeal involvement
;; ___ Lasts 1 to 7 days
;; ___ Lasts longer than 7 days
;; ___ Occurs once a year or less
;; ___ Occurs 1 to 2 times a year
;; ___ Occurs 2 to 4 times a year
;; ___ Occurs 5 to 8 times a year
;; ___ Occurs more than 8 times a year
;;
;; d. Does the Veteran have erythromelalgia?
;; ___ Yes ___ No
;;
;; NOTE: Characteristic attack of erythromelalgia consists of burning pain in
;; the hands, feet or both, usually bilateral and symmetrical, with increased
;; skin temperature and redness, occurring at warm ambient temperatures.
;;
;; If yes, indicate severity and frequency of characteristic attacks:
;; ___ Do not restrict most routine daily activities
;; ___ Restrict most routine daily activities
;; ___ Occur less than 3 times a week
;; ___ Occur at least 3 times a week
;; ___ Occur daily
;; ___ Occur more than once a day
;; ___ Last an average of more than 2 hours each
;; ___ Respond to treatment
;; ___ Respond poorly to treatment
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQAV2 10874 printed Apr 09, 2024@20:46:15 Page 2
DVBCQAV2 ;;ALB-CIOFO/ECF,SBW - ARTERIES AND VEINS QUESTIONNAIRE ; 20/JUNE/2011
+1 ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;;
+5 ;; 1. Diagnosis
+6 ;; Does the Veteran now have or has he/she ever had a vascular disease
+7 ;; (arterial or venous)?
+8 ;; ___ Yes ___ No
+9 ;;
+10 ;; If yes, provide only diagnoses that pertain to vascular conditions:
+11 ;; Diagnosis #1: ___________________
+12 ;; ICD code(s): ___________________
+13 ;; Date of diagnosis: ______________
+14 ;;
+15 ;; Diagnosis #2: ___________________
+16 ;; ICD code(s): ___________________
+17 ;; Date of diagnosis: ______________
+18 ;;
+19 ;; Diagnosis #3: ___________________
+20 ;; ICD code(s): ___________________
+21 ;; Date of diagnosis: ______________
+22 ;;
+23 ;; If there are additional diagnoses that pertain to vascular diseases,
+24 ;; list using above format: ____________________________________________________
+25 ;;
+26 ;; 2. Medical history
+27 ;; a. Describe the cause/onset of the Veteran's current vascular condition(s)
+28 ;; (brief summary): ____________________________________________________________
+29 ;;
+30 ;; b. Type of vascular disease condition: (Check all that apply)
+31 ;; ___ Section I: Varicose veins and/or post-phlebitic syndrome
+32 ;; ___ Section II: Peripheral vascular disease, aneurysm of any large
+33 ;; artery (other than aorta), arteriosclerosis obliterans or
+34 ;; thrombo-angiitis obliterans (Buerger's Disease)
+35 ;; ___ Section III: Aortic aneurysm
+36 ;; ___ Section IV: Aneurysm of a small artery
+37 ;; ___ Section V: Raynaud's syndrome
+38 ;; ___ Section VI: Arteriovenous (AV) fistula, angioneurotic edema or
+39 ;; erythromelalgia
+40 ;; If checked, complete appropriate Section I-VI.
+41 ;; Regardless of checked condition, complete Section VII.
+42 ;;^TOF^
+43 ;; Section I: Varicose veins and/or post-phlebitic syndrome
+44 ;;
+45 ;; Does the Veteran have varicose veins or post-phlebitic syndrome of any
+46 ;; etiology?
+47 ;; ___ Yes ___ No
+48 ;;
+49 ;; If yes, check all symptoms that apply and indicate extremity affected:
+50 ;; ___ Asymptomatic palpable varicose veins __ Right __ Left __ Both
+51 ;; ___ Asymptomatic visible varicose veins __ Right __ Left __ Both
+52 ;; ___ Aching and fatigue in leg after
+53 ;; prolonged standing or walking __ Right __ Left __ Both
+54 ;; ___ Symptoms relieved by elevation of
+55 ;; extremity __ Right __ Left __ Both
+56 ;; ___ Symptoms relieved by compression hosiery __ Right __ Left __ Both
+57 ;;
+58 ;; If yes, check all findings and/or signs that apply and indicate extremity
+59 ;; affected:
+60 ;; ___ Incipient stasis pigmentation or eczema __ Right __ Left __ Both
+61 ;; ___ Persistent stasis pigmentation or eczema __ Right __ Left __ Both
+62 ;; ___ Intermittent ulceration __ Right __ Left __ Both
+63 ;; ___ Intermittent edema of extremity __ Right __ Left __ Both
+64 ;; ___ Persistent edema that is incompletely
+65 ;; relieved by elevation of extremity __ Right __ Left __ Both
+66 ;; ___ Persistent edema __ Right __ Left __ Both
+67 ;; ___ Persistent subcutaneous induration __ Right __ Left __ Both
+68 ;; ___ Massive board-like edema __ Right __ Left __ Both
+69 ;; ___ Constant pain at rest __ Right __ Left __ Both
+70 ;;
+71 ;; Section II: Peripheral vascular disease, aneurysm of any large artery
+72 ;; (other than aorta), arteriosclerosis obliterans or thrombo-angiitis
+73 ;; obliterans (Buerger's Disease)
+74 ;;
+75 ;; a. Has the Veteran ever been diagnosed with: (check all that apply)?
+76 ;; ___ Peripheral vascular disease
+77 ;; ___ Aneurysm of any large artery (other than aorta)
+78 ;; ___ Arteriosclerosis obliterans
+79 ;; ___ Thrombo-angiitis obliterans (Buerger's Disease)
+80 ;; ___ None of the above
+81 ;; If any of the above conditions are checked, answer questions b-f.
+82 ;;
+83 ;; b. Has the Veteran undergone surgery for any of these listed conditions?
+84 ;; ___ Yes ___ No
+85 ;; If yes, type of surgery: ___________________ Date: ____________
+86 ;;
+87 ;; c. Has the Veteran undergone any procedure (other than surgery) for
+88 ;; revascularization?
+89 ;; ___ Yes ___ No
+90 ;; If yes, type of procedure: ___________________ Date: __________
+91 ;;^TOF^
+92 ;; d. Indicate severity of current signs and symptoms and indicate extremity
+93 ;; affected: (check all that apply):
+94 ;; ___ Claudication on walking more than 100
+95 ;; yards __ Right __ Left __ Both
+96 ;; ___ Claudication on walking between 25 and 100
+97 ;; yards on a level grade at 2 miles per hour __ Right __ Left __ Both
+98 ;; ___ Claudication on walking less than 25 yards
+99 ;; on a level grade at 2 miles per hour __ Right __ Left __ Both
+100 ;; ___ Persistent coldness of the extremity __ Right __ Left __ Both
+101 ;; ___ Diminished peripheral pulses __ Right __ Left __ Both
+102 ;; ___ Ischemic limb pain at rest __ Right __ Left __ Both
+103 ;; ___ Trophic changes (thin skin, absence of
+104 ;; hair, dystrophic nails) __ Right __ Left __ Both
+105 ;; ___ 1 or more deep ischemic ulcers __ Right __ Left __ Both
+106 ;;
+107 ;; Section III: Aortic aneurysm
+108 ;;
+109 ;; a. Has the Veteran ever been diagnosed with an aortic aneurysm?
+110 ;; ___ Yes ___ No
+111 ;; If yes, has the Veteran had a surgical procedure for an aortic aneurysm?
+112 ;; ___ Yes ___ No
+113 ;; If yes, indicate type of surgery: _____________________ Date: __________
+114 ;;
+115 ;; b. Does the Veteran currently have an aortic aneurysm?
+116 ;; ___ Yes ___ No
+117 ;; If yes, indicate severity:
+118 ;; 5 centimeters or larger in diameter: ___ Yes ___ No
+119 ;; Symptomatic ___ Yes ___ No
+120 ;; Precludes exertion ___ Yes ___ No
+121 ;;
+122 ;; c. Does the Veteran have any post-surgical residuals due to treatment for
+123 ;; aortic aneurysm?
+124 ;; ___ Yes ___ No
+125 ;; If yes, describe: _______________________________________________________
+126 ;; (If there are symptoms or post-surgical residuals, also complete
+127 ;; appropriate Questionnaire according to body system affected.)
+128 ;;
+129 ;; Section IV: Aneurysm of a small artery
+130 ;;
+131 ;; a. Has the Veteran been diagnosed with an aneurysm of a small artery?
+132 ;; ___ Yes ___ No
+133 ;; If yes, has the Veteran had a surgical procedure for an aneurysm of a small
+134 ;; artery?
+135 ;; ___ Yes ___ No
+136 ;; If yes, indicate type of surgery: ______________________ Date: __________
+137 ;;^TOF^
+138 ;; b. Does the Veteran currently have an aneurysm of a small artery?
+139 ;; ___ Yes ___ No
+140 ;; If yes, is the condition symptomatic?
+141 ;; ___ Yes ___ No
+142 ;; If yes, describe: ________________________________________________________
+143 ;; Also, complete appropriate Questionnaire according to body system
+144 ;; affected.
+145 ;;
+146 ;; c. Does the Veteran have any post-surgical residuals due to treatment for
+147 ;; an aneurysm of a small artery?
+148 ;; ___ Yes ___ No
+149 ;; If yes, describe: ________________________________________________________
+150 ;; Also, complete appropriate Questionnaire according to body system
+151 ;; affected.
+152 ;;
+153 ;; Section V: Raynaud's syndrome
+154 ;;
+155 ;; a. Does the Veteran have Raynaud's syndrome?
+156 ;; ___ Yes ___ No
+157 ;; If yes, complete this section.
+158 ;;
+159 ;; b. Does the Veteran have characteristic attacks?
+160 ;; ___ Yes ___ No
+161 ;; If yes, indicate frequency of characteristic attacks:
+162 ;; ___ Less than once a week
+163 ;; ___ 1 to 3 times a week
+164 ;; ___ 4 to 6 times a week
+165 ;; ___ At least daily
+166 ;; NOTE: Characteristic attacks consist of sequential color changes of the digits
+167 ;; of one or more extremities lasting minutes to hours, sometimes with pain and
+168 ;; paresthesias, and precipitated by exposure to cold or by emotional upsets.
+169 ;;
+170 ;; c. Does the Veteran have 2 or more digital ulcers?
+171 ;; ___ Yes ___ No
+172 ;;
+173 ;; d. Does the Veteran have autoamputation of one or more digits?
+174 ;; ___ Yes ___ No
+175 ;;
+176 ;; Section VI: Arteriovenous (AV) fistula, angioneurotic edema or
+177 ;; erythromelalgia
+178 ;;
+179 ;; a. Does the Veteran have arteriovenous (AV) fistula, angioneurotic edema or
+180 ;; erythromelalgia?
+181 ;; ___ Yes ___ No
+182 ;; If yes, complete this section.
+183 ;;^TOF^
+184 ;; b. Does the Veteran have a traumatic arteriovenous (AV) fistula?
+185 ;; ___ Yes ___ No
+186 ;; If yes, complete the following:
+187 ;; 1. Indicate site of traumatic AV fistula:
+188 ;; ___ Right upper extremity ___ Right lower extremity
+189 ;; ___ Left upper extremity ___ Left lower extremity
+190 ;; ___ Other location, specify ________________
+191 ;; 2. Indicate findings:
+192 ;; ___ Edema
+193 ;; ___ Stasis dermatitis
+194 ;; ___ Ulceration
+195 ;; ___ Cellulitis
+196 ;; ___ Enlarged heart
+197 ;; ___ Wide pulse pressure
+198 ;; ___ Tachycardia
+199 ;; ___ High output heart failure
+200 ;; 3. Is there more than one traumatic AV fistula?
+201 ;; ___ Yes ___ No
+202 ;; If yes, provide location and findings for each:________________________
+203 ;;
+204 ;; c. Does the Veteran have angioneurotic edema?
+205 ;; ___ Yes ___ No
+206 ;; If yes, indicate severity and frequency of characteristic attacks:
+207 ;; ___ Without laryngeal involvement
+208 ;; ___ With laryngeal involvement
+209 ;; ___ Lasts 1 to 7 days
+210 ;; ___ Lasts longer than 7 days
+211 ;; ___ Occurs once a year or less
+212 ;; ___ Occurs 1 to 2 times a year
+213 ;; ___ Occurs 2 to 4 times a year
+214 ;; ___ Occurs 5 to 8 times a year
+215 ;; ___ Occurs more than 8 times a year
+216 ;;
+217 ;; d. Does the Veteran have erythromelalgia?
+218 ;; ___ Yes ___ No
+219 ;;
+220 ;; NOTE: Characteristic attack of erythromelalgia consists of burning pain in
+221 ;; the hands, feet or both, usually bilateral and symmetrical, with increased
+222 ;; skin temperature and redness, occurring at warm ambient temperatures.
+223 ;;
+224 ;; If yes, indicate severity and frequency of characteristic attacks:
+225 ;; ___ Do not restrict most routine daily activities
+226 ;; ___ Restrict most routine daily activities
+227 ;; ___ Occur less than 3 times a week
+228 ;; ___ Occur at least 3 times a week
+229 ;; ___ Occur daily
+230 ;; ___ Occur more than once a day
+231 ;; ___ Last an average of more than 2 hours each
+232 ;; ___ Respond to treatment
+233 ;; ___ Respond poorly to treatment
+234 QUIT
