DVBCQBC2 ;;ALB-CIOFO/ECF - HAIRY CELL LEUKEMIA QUESTIONNAIRE ; 5/10/2010
;;2.7;AMIE;**154**;Apr 10, 1995;Build 7
;
TXT ;
;; The Veteran has applied to the U. S. Department of Veterans Affairs for
;; disability benefits. Please complete this Questionnaire, which VA needs
;; for review of the application.
;;
;; 1. Diagnosis
;;
;; Does the Veteran now have or has he/she ever been diagnosed
;; with hairy cell leukemia or any other B-cell leukemia?
;; ___Yes ___No
;;
;; NOTE: Provide only diagnoses that pertain to hairy cell or any other
;; B-cell leukemias
;;
;; Diagnosis #1: _______________________
;; ICD code: ___________________________
;; Date of diagnosis #1: _______________
;;
;; Diagnosis #2: _______________________
;; ICD code: ___________________________
;; Date of diagnosis #2: _______________
;;
;; Diagnosis #3: _______________________
;; ICD code: ___________________________
;; Date of diagnosis #3: _______________
;;
;; If additional diagnoses that pertain to hairy cell leukemia or any
;; other B-cell leukemia, list using above format: ___________________
;;
;; 2. Status of disease
;;
;; ___ Active ___ Remission
;;
;; 3. Treatment
;;
;; ____ The Veteran is currently undergoing treatment for this leukemia
;; with surgical, radiation, immunotherapy, antineoplastic chemotherapy
;; and/or other therapeutic procedures.
;;
;; ____ The Veteran has completed treatment for this leukemia.
;;
;; Date of discontinuance of treatment: ______________
;;^TOF^
;; 4. Complications or residuals of treatment
;;
;; a. Does the Veteran currently have any complications or residuals of
;; treatment?
;;
;; ___Yes ___No
;;
;; b. Are there any complications or residuals requiring transfusion of
;; platelets or red cells?
;;
;; ___Yes ___No
;;
;; If yes, indicate frequency:
;;
;; ___ At least once per year but less than once every 3 months
;;
;; ___ At least once every 3 months
;;
;; ___ At least once every 6 weeks
;;
;; c. Are there any complications or residuals causing recurring infections?
;;
;; ___Yes ___No
;;
;; If yes, indicate frequency:
;;
;; ___ At least once per year but less than once every 3 months
;;
;; ___ At least once every 3 months
;;
;; ___ At least once every 6 weeks
;;
;;^TOF^
;; d. Are there any complications or residuals related to anemia?
;;
;; ___Yes ___No
;;
;; If yes, check all that apply:
;;
;; ___ Asymptomatic anemia
;;
;; ___ Requires continuous medication
;;
;; ___ Requiring bone marrow transplant Date:_________________
;;
;; ___ Symptomatic anemia (check signs and symptoms that apply)
;;
;; __ Weakness __ Easy fatigability __ Headaches
;;
;; __ Lightheadedness __ Shortness of breath
;;
;; __ Dyspnea on mild exertion
;;
;; __ Cardiomegaly __ Tachycardia __ Syncope
;;
;; __ High output congestive heart failure __ Dyspnea at rest
;;
;; ___ Other signs and/or symptoms: _____________________________
;;
;; _______________________________________________________________
;;
;; If available, provide most recent hemoglobin level
;;
;; (gm/100ml): _________ Date: ________
;;
;; If available, provide most recent platelet count: _____ Date: ________
;;
;; If any other residual complications are present, please specify: _____
;;
;; ______________________________________________________________________
;;
;;^TOF^
;; 5. Functional impact
;;
;; Does the Veteran's B-cell leukemia impact the Veteran's ability to work?
;;
;; ___Yes ___No
;;
;; If yes, describe impact, providing one or more examples: _________________
;;
;; __________________________________________________________________________
;;
;; 6. Remarks, if any _______________________________________________
;;
;; __________________________________________________________________________
;;
;; Physician signature: __________________________________ Date: ______________
;;
;; Physician printed name: ________________________________ Phone: _____________
;;
;; Medical license #: _______________________
;;
;; 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[HDVBCQBC2 4982 printed Apr 09, 2024@20:50:25 Page 2
DVBCQBC2 ;;ALB-CIOFO/ECF - HAIRY CELL LEUKEMIA QUESTIONNAIRE ; 5/10/2010
+1 ;;2.7;AMIE;**154**;Apr 10, 1995;Build 7
+2 ;
TXT ;
+1 ;; The Veteran has applied to the U. S. Department of Veterans Affairs for
+2 ;; disability benefits. Please complete this Questionnaire, which VA needs
+3 ;; for review of the application.
+4 ;;
+5 ;; 1. Diagnosis
+6 ;;
+7 ;; Does the Veteran now have or has he/she ever been diagnosed
+8 ;; with hairy cell leukemia or any other B-cell leukemia?
+9 ;; ___Yes ___No
+10 ;;
+11 ;; NOTE: Provide only diagnoses that pertain to hairy cell or any other
+12 ;; B-cell leukemias
+13 ;;
+14 ;; Diagnosis #1: _______________________
+15 ;; ICD code: ___________________________
+16 ;; Date of diagnosis #1: _______________
+17 ;;
+18 ;; Diagnosis #2: _______________________
+19 ;; ICD code: ___________________________
+20 ;; Date of diagnosis #2: _______________
+21 ;;
+22 ;; Diagnosis #3: _______________________
+23 ;; ICD code: ___________________________
+24 ;; Date of diagnosis #3: _______________
+25 ;;
+26 ;; If additional diagnoses that pertain to hairy cell leukemia or any
+27 ;; other B-cell leukemia, list using above format: ___________________
+28 ;;
+29 ;; 2. Status of disease
+30 ;;
+31 ;; ___ Active ___ Remission
+32 ;;
+33 ;; 3. Treatment
+34 ;;
+35 ;; ____ The Veteran is currently undergoing treatment for this leukemia
+36 ;; with surgical, radiation, immunotherapy, antineoplastic chemotherapy
+37 ;; and/or other therapeutic procedures.
+38 ;;
+39 ;; ____ The Veteran has completed treatment for this leukemia.
+40 ;;
+41 ;; Date of discontinuance of treatment: ______________
+42 ;;^TOF^
+43 ;; 4. Complications or residuals of treatment
+44 ;;
+45 ;; a. Does the Veteran currently have any complications or residuals of
+46 ;; treatment?
+47 ;;
+48 ;; ___Yes ___No
+49 ;;
+50 ;; b. Are there any complications or residuals requiring transfusion of
+51 ;; platelets or red cells?
+52 ;;
+53 ;; ___Yes ___No
+54 ;;
+55 ;; If yes, indicate frequency:
+56 ;;
+57 ;; ___ At least once per year but less than once every 3 months
+58 ;;
+59 ;; ___ At least once every 3 months
+60 ;;
+61 ;; ___ At least once every 6 weeks
+62 ;;
+63 ;; c. Are there any complications or residuals causing recurring infections?
+64 ;;
+65 ;; ___Yes ___No
+66 ;;
+67 ;; If yes, indicate frequency:
+68 ;;
+69 ;; ___ At least once per year but less than once every 3 months
+70 ;;
+71 ;; ___ At least once every 3 months
+72 ;;
+73 ;; ___ At least once every 6 weeks
+74 ;;
+75 ;;^TOF^
+76 ;; d. Are there any complications or residuals related to anemia?
+77 ;;
+78 ;; ___Yes ___No
+79 ;;
+80 ;; If yes, check all that apply:
+81 ;;
+82 ;; ___ Asymptomatic anemia
+83 ;;
+84 ;; ___ Requires continuous medication
+85 ;;
+86 ;; ___ Requiring bone marrow transplant Date:_________________
+87 ;;
+88 ;; ___ Symptomatic anemia (check signs and symptoms that apply)
+89 ;;
+90 ;; __ Weakness __ Easy fatigability __ Headaches
+91 ;;
+92 ;; __ Lightheadedness __ Shortness of breath
+93 ;;
+94 ;; __ Dyspnea on mild exertion
+95 ;;
+96 ;; __ Cardiomegaly __ Tachycardia __ Syncope
+97 ;;
+98 ;; __ High output congestive heart failure __ Dyspnea at rest
+99 ;;
+100 ;; ___ Other signs and/or symptoms: _____________________________
+101 ;;
+102 ;; _______________________________________________________________
+103 ;;
+104 ;; If available, provide most recent hemoglobin level
+105 ;;
+106 ;; (gm/100ml): _________ Date: ________
+107 ;;
+108 ;; If available, provide most recent platelet count: _____ Date: ________
+109 ;;
+110 ;; If any other residual complications are present, please specify: _____
+111 ;;
+112 ;; ______________________________________________________________________
+113 ;;
+114 ;;^TOF^
+115 ;; 5. Functional impact
+116 ;;
+117 ;; Does the Veteran's B-cell leukemia impact the Veteran's ability to work?
+118 ;;
+119 ;; ___Yes ___No
+120 ;;
+121 ;; If yes, describe impact, providing one or more examples: _________________
+122 ;;
+123 ;; __________________________________________________________________________
+124 ;;
+125 ;; 6. Remarks, if any _______________________________________________
+126 ;;
+127 ;; __________________________________________________________________________
+128 ;;
+129 ;; Physician signature: __________________________________ Date: ______________
+130 ;;
+131 ;; Physician printed name: ________________________________ Phone: _____________
+132 ;;
+133 ;; Medical license #: _______________________
+134 ;;
+135 ;; Physician address: __________________________________________________________
+136 ;;
+137 ;; NOTE: VA may request additional medical information, including additional
+138 ;; examinations if necessary to complete VA's review of the Veteran's
+139 ;; application.
+140 ;; ^END^
+141 QUIT
