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Routine: DVBCQAV3

DVBCQAV3.m

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DVBCQAV3 ;;ALB-CIOFO/ECF,SBW - ARTERIES AND VEINS QUESTIONNAIRE  ; 9/JUN/2011

 ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2

 ;

TXT ;

 ;;^TOF^

 ;; Section VII: Miscellaneous Issues

 ;; 1.  Amputations

 ;; Has the Veteran had an amputation of an extremity due to a vascular

 ;; condition?

 ;; ___ Yes    ___ No

 ;; If yes, also complete Amputations Questionnaire.

 ;;

 ;; 2. Assistive devices

 ;; a. Does the Veteran use any assistive device(s) as a normal mode of

 ;; locomotion, although occasional locomotion by other methods may be possible?

 ;; ___ Yes    ___ No

 ;; If yes, identify assistive device(s) used (check all that apply and indicate

 ;; frequency):

 ;;    __ Wheelchair  Frequency of use:  __ Occasional   __ Regular   __ Constant

 ;;    __ Brace(s)    Frequency of use:  __ Occasional   __ Regular   __ Constant

 ;;    __ Crutch(es)  Frequency of use:  __ Occasional   __ Regular   __ Constant

 ;;    __ Cane(s)     Frequency of use:  __ Occasional   __ Regular   __ Constant

 ;;    __ Walker      Frequency of use:  __ Occasional   __ Regular   __ Constant

 ;;    __ Other: ________________________________________________________________

 ;;                   Frequency of use:  __ Occasional   __ Regular   __ Constant

 ;;

 ;; b. If the Veteran uses any assistive devices, specify the condition and

 ;; identify the assistive device used for each condition: ______________________

 ;;

 ;; 3. Remaining effective function of the extremities

 ;; Due to a vascular condition, is there functional impairment of an extremity

 ;; such that no effective function remains other than that which would be

 ;; equally well served by an amputation with prosthesis? (Functions of the

 ;; upper extremity include grasping, manipulation, etc., while functions for

 ;; the lower extremity include balance and propulsion, etc.)

 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would

 ;; equally serve the Veteran.

 ;; ___ No

 ;;     If yes, indicate extremity(ies) (check all extremities for which

 ;;     this applies):

 ;;     ___ Right upper   ___ Left upper   ___ Right lower    ___ Left lower

 ;;     For each checked extremity, describe loss of effective function,

 ;;     identify the condition causing loss of function, and provide specific

 ;;     examples (brief summary): _______________________________________________

 ;;

 ;; 4. Other pertinent physical findings, complications, conditions, signs

 ;; and/or symptoms

 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any

 ;; conditions or to the treatment of any conditions listed in the Diagnosis

 ;; section above?

 ;; ___ Yes    ___ No

 ;; If yes, are any of the scars painful and/or unstable, or is the total area

 ;; of all related scars 39 square cm (6 square inches) or greater?

 ;;     ___ Yes    ___ No

 ;;         If yes, also complete a Scars Questionnaire.

 ;;

 ;; b. Does the Veteran have any other pertinent physical findings,

 ;; complications, conditions, signs or symptoms related to the conditions

 ;; listed in the Diagnosis section above?

 ;; ___ Yes    ___ No

 ;; If yes, describe (brief summary): ___________________________________________

 ;;

 ;; 5. Diagnostic testing

 ;; a. Has ankle/brachial index testing been performed?

 ;; ___ Yes    ___ No   ___ Unable to perform, provide reason: _____________________

 ;; If yes, provide most recent results:

 ;;    ___ Right ankle/brachial index: ___________   Date: ________________

 ;;    ___ Left ankle/brachial index: ____________   Date: ________________

 ;;

 ;; NOTE: An ankle/brachial index is required for peripheral vascular disease

 ;; or aneurysm of any large artery (other than aorta), arteriosclerosis

 ;; obliterans or thrombo-angiitis obliterans (Buerger's disease) if not of

 ;; record, or if there has been an intervening change in the Veteran's

 ;; peripheral vascular condition.

 ;;

 ;; b. 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):

 ;; _____________________________________________________________________________

 ;;

 ;; 6. Functional impact

 ;; Does the Veteran's vascular condition(s) impact his or her ability to work?

 ;; ___ Yes    ___ No

 ;; If yes, describe impact of each of the Veteran's vascular condition,

 ;; providing one or more examples: _____________________________________________

 ;; _____________________________________________________________________________

 ;;

 ;; 7. Remarks, if any: _________________________________________________________

 ;; _____________________________________________________________________________

 ;;

 ;; Physician signature: _____________________________________ Date: ____________

 ;;

 ;; Physician printed name: _____________________________________________________

 ;;

 ;; Medical license #: __________________________________________________________

 ;;

 ;; Physician address: __________________________________________________________

 ;;

 ;; Phone: _____________________________     FAX: _______________________________

 ;;

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

 ;; examinations if necessary to complete VA's review of the Veteran's application.

 ;;^END^

 Q