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Routine: DVBCQAV3

DVBCQAV3.m

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  1. DVBCQAV3 ;;ALB-CIOFO/ECF,SBW - ARTERIES AND VEINS QUESTIONNAIRE  ; 9/JUN/2011
  1.  ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;;^TOF^
  1.  ;; Section VII: Miscellaneous Issues
  1.  ;; 1.  Amputations
  1.  ;; Has the Veteran had an amputation of an extremity due to a vascular
  1.  ;; condition?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, also complete Amputations Questionnaire.
  1.  ;;
  1.  ;; 2. Assistive devices
  1.  ;; a. Does the Veteran use any assistive device(s) as a normal mode of
  1.  ;; locomotion, although occasional locomotion by other methods may be possible?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, identify assistive device(s) used (check all that apply and indicate
  1.  ;; frequency):
  1.  ;;    __ Wheelchair  Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;    __ Brace(s)    Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;    __ Crutch(es)  Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;    __ Cane(s)     Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;    __ Walker      Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;    __ Other: ________________________________________________________________
  1.  ;;                   Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;
  1.  ;; b. If the Veteran uses any assistive devices, specify the condition and
  1.  ;; identify the assistive device used for each condition: ______________________
  1.  ;;
  1.  ;; 3. Remaining effective function of the extremities
  1.  ;; Due to a vascular condition, is there functional impairment of an extremity
  1.  ;; such that no effective function remains other than that which would be
  1.  ;; equally well served by an amputation with prosthesis? (Functions of the
  1.  ;; upper extremity include grasping, manipulation, etc., while functions for
  1.  ;; the lower extremity include balance and propulsion, etc.)
  1.  ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
  1.  ;; equally serve the Veteran.
  1.  ;; ___ No
  1.  ;;     If yes, indicate extremity(ies) (check all extremities for which
  1.  ;;     this applies):
  1.  ;;     ___ Right upper   ___ Left upper   ___ Right lower    ___ Left lower
  1.  ;;     For each checked extremity, describe loss of effective function,
  1.  ;;     identify the condition causing loss of function, and provide specific
  1.  ;;     examples (brief summary): _______________________________________________
  1.  ;;
  1.  ;; 4. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, are any of the scars painful and/or unstable, or is the total area
  1.  ;; of all related scars 39 square cm (6 square inches) or greater?
  1.  ;;     ___ Yes    ___ No
  1.  ;;         If yes, also complete a Scars Questionnaire.
  1.  ;;
  1.  ;; b. Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs or symptoms related to the conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, describe (brief summary): ___________________________________________
  1.  ;;
  1.  ;; 5. Diagnostic testing
  1.  ;; a. Has ankle/brachial index testing been performed?
  1.  ;; ___ Yes    ___ No   ___ Unable to perform, provide reason: _____________________
  1.  ;; If yes, provide most recent results:
  1.  ;;    ___ Right ankle/brachial index: ___________   Date: ________________
  1.  ;;    ___ Left ankle/brachial index: ____________   Date: ________________
  1.  ;;
  1.  ;; NOTE: An ankle/brachial index is required for peripheral vascular disease
  1.  ;; or aneurysm of any large artery (other than aorta), arteriosclerosis
  1.  ;; obliterans or thrombo-angiitis obliterans (Buerger's disease) if not of
  1.  ;; record, or if there has been an intervening change in the Veteran's
  1.  ;; peripheral vascular condition.
  1.  ;;
  1.  ;; b. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 6. Functional impact
  1.  ;; Does the Veteran's vascular condition(s) impact his or her ability to work?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, describe impact of each of the Veteran's vascular condition,
  1.  ;; providing one or more examples: _____________________________________________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 7. Remarks, if any: _________________________________________________________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; Physician signature: _____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: _____________________________________________________
  1.  ;;
  1.  ;; Medical license #: __________________________________________________________
  1.  ;;
  1.  ;; Physician address: __________________________________________________________
  1.  ;;
  1.  ;; Phone: _____________________________     FAX: _______________________________
  1.  ;;
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's application.
  1.  ;;^END^
  1.  Q