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Routine: DVBCQBC4

DVBCQBC4.m

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  1. DVBCQBC4 ;;ALB-CIOFO/ECF - HAIRY CELL LEUKEMIA QUESTIONNAIRE ; 5/10/2010
  1.  ;;2.7;AMIE;**159**;Apr 10, 1995;Build 5
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs
  1.  ;; (VA) for disability benefits.  VA will consider the information you
  1.  ;; provide on this questionnaire as part of their evaluation in processing
  1.  ;; the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;;    
  1.  ;;    Does the Veteran now have or has he/she ever been diagnosed
  1.  ;;    with hairy cell leukemia or any other B-cell leukemia? 
  1.  ;;    ___Yes  ___No
  1.  ;;
  1.  ;;    NOTE: Provide only diagnoses that pertain to hairy cell or any other
  1.  ;;    B-cell leukemias
  1.  ;;  
  1.  ;;    Diagnosis #1: _______________________ 
  1.  ;;    ICD code: ___________________________
  1.  ;;    Date of diagnosis #1: _______________
  1.  ;;
  1.  ;;    Diagnosis #2: _______________________ 
  1.  ;;    ICD code: ___________________________
  1.  ;;    Date of diagnosis #2: _______________
  1.  ;;
  1.  ;;    Diagnosis #3: _______________________ 
  1.  ;;    ICD code: ___________________________
  1.  ;;    Date of diagnosis #3: _______________
  1.  ;; 
  1.  ;;    If additional diagnoses that pertain to hairy cell leukemia or any
  1.  ;;    other B-cell leukemia, list using above format: ___________________
  1.  ;;
  1.  ;; 2. Status of disease    
  1.  ;;
  1.  ;;    ___ Active     ___ Remission
  1.  ;;
  1.  ;; 3. Treatment
  1.  ;;
  1.  ;;    ____ The Veteran is currently undergoing treatment for this leukemia
  1.  ;;    with surgical, radiation, immunotherapy, antineoplastic chemotherapy
  1.  ;;    and/or other therapeutic procedures.
  1.  ;;
  1.  ;;    ____ The Veteran has completed treatment for this leukemia.
  1.  ;;
  1.  ;;         Date of discontinuance of treatment: ______________
  1.  ;;^TOF^
  1.  ;; 4. Complications or residuals of treatment
  1.  ;;
  1.  ;;    a. Does the Veteran currently have any complications or residuals of 
  1.  ;;       treatment?
  1.  ;;
  1.  ;;        ___Yes    ___No
  1.  ;;
  1.  ;;    b. Are there any complications or residuals requiring transfusion of
  1.  ;;       platelets or red cells? 
  1.  ;;
  1.  ;;        ___Yes    ___No
  1.  ;;
  1.  ;;        If yes, indicate frequency:
  1.  ;;
  1.  ;;           ___ At least once per year but less than once every 3 months
  1.  ;;
  1.  ;;           ___ At least once every 3 months
  1.  ;;
  1.  ;;           ___ At least once every 6 weeks
  1.  ;;
  1.  ;;    c. Are there any complications or residuals causing recurring infections?
  1.  ;;
  1.  ;;        ___Yes    ___No
  1.  ;;
  1.  ;;        If yes, indicate frequency:
  1.  ;;
  1.  ;;           ___ At least once per year but less than once every 3 months
  1.  ;;
  1.  ;;           ___ At least once every 3 months
  1.  ;;
  1.  ;;           ___ At least once every 6 weeks
  1.  ;;
  1.  ;;^TOF^
  1.  ;;    d. Are there any complications or residuals related to anemia?
  1.  ;;
  1.  ;;        ___Yes    ___No
  1.  ;;
  1.  ;;        If yes, check all that apply:
  1.  ;;
  1.  ;;           ___ Asymptomatic anemia
  1.  ;;
  1.  ;;           ___ Requires continuous medication
  1.  ;;
  1.  ;;           ___ Requiring bone marrow transplant    Date:_________________
  1.  ;;
  1.  ;;           ___ Symptomatic anemia (check signs and symptoms that apply)
  1.  ;;
  1.  ;;               __ Weakness         __ Easy fatigability      __ Headaches
  1.  ;;        
  1.  ;;               __ Lightheadedness  __ Shortness of breath     
  1.  ;;
  1.  ;;               __ Dyspnea on mild exertion
  1.  ;;
  1.  ;;               __ Cardiomegaly     __ Tachycardia  __ Syncope 
  1.  ;; 
  1.  ;;               __ High output congestive heart failure      __ Dyspnea at rest
  1.  ;;
  1.  ;;               ___  Other signs and/or symptoms: _____________________________
  1.  ;;
  1.  ;;               _______________________________________________________________
  1.  ;;
  1.  ;;        If available, provide most recent hemoglobin level 
  1.  ;;
  1.  ;;              (gm/100ml): _________ Date: ________
  1.  ;;
  1.  ;;        If available, provide most recent platelet count: _____ Date: ________
  1.  ;;
  1.  ;;        If any other residual complications are present, please specify: _____
  1.  ;;
  1.  ;;        ______________________________________________________________________
  1.  ;;
  1.  ;;^TOF^
  1.  ;; 5. Functional impact
  1.  ;;
  1.  ;;    Does the Veteran's B-cell leukemia impact the Veteran's ability to work?
  1.  ;;
  1.  ;;    ___Yes   ___No 
  1.  ;;
  1.  ;;    If yes, describe impact, providing one or more examples: _________________
  1.  ;;
  1.  ;;    __________________________________________________________________________
  1.  ;;
  1.  ;; 6. Remarks, if any __________________________________________________________
  1.  ;;
  1.  ;;    __________________________________________________________________________
  1.  ;;
  1.  ;; Physician signature: __________________________________  Date: ______________
  1.  ;;
  1.  ;; Physician printed name: ________________________________ Phone: _____________
  1.  ;;
  1.  ;; Medical license #: _______________________
  1.  ;;
  1.  ;; Physician address: __________________________________________________________
  1.  ;; 
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's
  1.  ;; application.                         
  1.  ;; ^END^
  1.  Q