DVBCQBC4 ;;ALB-CIOFO/ECF - HAIRY CELL LEUKEMIA QUESTIONNAIRE ; 5/10/2010
;;2.7;AMIE;**159**;Apr 10, 1995;Build 5
;
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 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[HDVBCQBC4 5056 printed Dec 13, 2024@01:45:46 Page 2
DVBCQBC4 ;;ALB-CIOFO/ECF - HAIRY CELL LEUKEMIA QUESTIONNAIRE ; 5/10/2010
+1 ;;2.7;AMIE;**159**;Apr 10, 1995;Build 5
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran now have or has he/she ever been diagnosed
+10 ;; with hairy cell leukemia or any other B-cell leukemia?
+11 ;; ___Yes ___No
+12 ;;
+13 ;; NOTE: Provide only diagnoses that pertain to hairy cell or any other
+14 ;; B-cell leukemias
+15 ;;
+16 ;; Diagnosis #1: _______________________
+17 ;; ICD code: ___________________________
+18 ;; Date of diagnosis #1: _______________
+19 ;;
+20 ;; Diagnosis #2: _______________________
+21 ;; ICD code: ___________________________
+22 ;; Date of diagnosis #2: _______________
+23 ;;
+24 ;; Diagnosis #3: _______________________
+25 ;; ICD code: ___________________________
+26 ;; Date of diagnosis #3: _______________
+27 ;;
+28 ;; If additional diagnoses that pertain to hairy cell leukemia or any
+29 ;; other B-cell leukemia, list using above format: ___________________
+30 ;;
+31 ;; 2. Status of disease
+32 ;;
+33 ;; ___ Active ___ Remission
+34 ;;
+35 ;; 3. Treatment
+36 ;;
+37 ;; ____ The Veteran is currently undergoing treatment for this leukemia
+38 ;; with surgical, radiation, immunotherapy, antineoplastic chemotherapy
+39 ;; and/or other therapeutic procedures.
+40 ;;
+41 ;; ____ The Veteran has completed treatment for this leukemia.
+42 ;;
+43 ;; Date of discontinuance of treatment: ______________
+44 ;;^TOF^
+45 ;; 4. Complications or residuals of treatment
+46 ;;
+47 ;; a. Does the Veteran currently have any complications or residuals of
+48 ;; treatment?
+49 ;;
+50 ;; ___Yes ___No
+51 ;;
+52 ;; b. Are there any complications or residuals requiring transfusion of
+53 ;; platelets or red cells?
+54 ;;
+55 ;; ___Yes ___No
+56 ;;
+57 ;; If yes, indicate frequency:
+58 ;;
+59 ;; ___ At least once per year but less than once every 3 months
+60 ;;
+61 ;; ___ At least once every 3 months
+62 ;;
+63 ;; ___ At least once every 6 weeks
+64 ;;
+65 ;; c. Are there any complications or residuals causing recurring infections?
+66 ;;
+67 ;; ___Yes ___No
+68 ;;
+69 ;; If yes, indicate frequency:
+70 ;;
+71 ;; ___ At least once per year but less than once every 3 months
+72 ;;
+73 ;; ___ At least once every 3 months
+74 ;;
+75 ;; ___ At least once every 6 weeks
+76 ;;
+77 ;;^TOF^
+78 ;; d. Are there any complications or residuals related to anemia?
+79 ;;
+80 ;; ___Yes ___No
+81 ;;
+82 ;; If yes, check all that apply:
+83 ;;
+84 ;; ___ Asymptomatic anemia
+85 ;;
+86 ;; ___ Requires continuous medication
+87 ;;
+88 ;; ___ Requiring bone marrow transplant Date:_________________
+89 ;;
+90 ;; ___ Symptomatic anemia (check signs and symptoms that apply)
+91 ;;
+92 ;; __ Weakness __ Easy fatigability __ Headaches
+93 ;;
+94 ;; __ Lightheadedness __ Shortness of breath
+95 ;;
+96 ;; __ Dyspnea on mild exertion
+97 ;;
+98 ;; __ Cardiomegaly __ Tachycardia __ Syncope
+99 ;;
+100 ;; __ High output congestive heart failure __ Dyspnea at rest
+101 ;;
+102 ;; ___ Other signs and/or symptoms: _____________________________
+103 ;;
+104 ;; _______________________________________________________________
+105 ;;
+106 ;; If available, provide most recent hemoglobin level
+107 ;;
+108 ;; (gm/100ml): _________ Date: ________
+109 ;;
+110 ;; If available, provide most recent platelet count: _____ Date: ________
+111 ;;
+112 ;; If any other residual complications are present, please specify: _____
+113 ;;
+114 ;; ______________________________________________________________________
+115 ;;
+116 ;;^TOF^
+117 ;; 5. Functional impact
+118 ;;
+119 ;; Does the Veteran's B-cell leukemia impact the Veteran's ability to work?
+120 ;;
+121 ;; ___Yes ___No
+122 ;;
+123 ;; If yes, describe impact, providing one or more examples: _________________
+124 ;;
+125 ;; __________________________________________________________________________
+126 ;;
+127 ;; 6. Remarks, if any __________________________________________________________
+128 ;;
+129 ;; __________________________________________________________________________
+130 ;;
+131 ;; Physician signature: __________________________________ Date: ______________
+132 ;;
+133 ;; Physician printed name: ________________________________ Phone: _____________
+134 ;;
+135 ;; Medical license #: _______________________
+136 ;;
+137 ;; Physician address: __________________________________________________________
+138 ;;
+139 ;; NOTE: VA may request additional medical information, including additional
+140 ;; examinations if necessary to complete VA's review of the Veteran's
+141 ;; application.
+142 ;; ^END^
+143 QUIT
