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Routine: DVBCQBR2

DVBCQBR2.m

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  1. DVBCQBR2 ;;ALB-CIOFO/SBW - Breast Conditions and Disorders QUESTIONNAIRE  ; 27/JUNE/2011
  1.  ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1.  ;; disability benefits.  VA will consider the information you provide on this
  1.  ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;; Does the Veteran now have or has he/she ever had a disorder of the breast(s)?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide only diagnoses that pertain to the breast(s):
  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 there are additional diagnoses that pertain to breast(s), list using above
  1.  ;; format: _____________________________________________________________________
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;; a. Describe the history (including onset and course) of the Veteran's breast
  1.  ;; condition: __________________________________________________________________
  1.  ;;
  1.  ;; b. Does the Veteran have, or have a history of, a neoplasm of the breast?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, is or was there a malignant neoplasm?
  1.  ;;      ___ Yes   ___ No
  1.  ;;      If yes, ___ Right   ___ Left   ___ Both
  1.  ;;      If yes, were there or are there currently any metastases?
  1.  ;;          ___ Yes   ___ No
  1.  ;;          If yes, describe locations: ___________________
  1.  ;; If yes, is or was there a benign neoplasm?
  1.  ;;      ___ Yes   ___ No
  1.  ;;      If yes, ___ Right   ___ Left   ___ Both
  1.  ;;^TOF^
  1.  ;; 3. Treatment/surgery
  1.  ;; a. Has the Veteran completed any type of treatment or is the Veteran currently
  1.  ;; undergoing treatment for a benign or malignant neoplasm and/or metastases?
  1.  ;; ___ Yes   ___ No; watchful waiting
  1.  ;; If yes, indicate treatment type(s) (check all that apply):
  1.  ;;    ___ Treatment completed; currently in watchful waiting status
  1.  ;;    ___ Surgery
  1.  ;;         If checked, describe: ___________________
  1.  ;;         Date(s) of surgery: __________
  1.  ;;    ___ Radiation therapy
  1.  ;;         Date of most recent treatment: ___________
  1.  ;;         Date of completion of treatment or anticipated date of completion:
  1.  ;;         _________
  1.  ;;         Side:  ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Antineoplastic chemotherapy
  1.  ;;         Date of most recent treatment: ___________
  1.  ;;         Date of completion of treatment or anticipated date of completion:
  1.  ;;         _________
  1.  ;;    ___ Other therapeutic procedure and/or treatment 
  1.  ;;         Date of most recent procedure: ___________
  1.  ;;         Date of completion of treatment or anticipated date of completion:
  1.  ;;         _________
  1.  ;;         Describe the other treatment and/or procedure: ______________________
  1.  ;;
  1.  ;; b. Has the Veteran undergone breast surgery?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate procedure type and severity (check all that apply):
  1.  ;;    ___ Wide local excision (For VA purposes, wide local excision means
  1.  ;;        removal of a portion of the breast tissue and includes partial
  1.  ;;        mastectomy, lumpectomy, tylectomy, segmentectomy, and quadrantectomy)
  1.  ;;                                               ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Simple (or total) mastectomy (For VA purposes, a simple (or total)
  1.  ;;        mastectomy means removal of all of the breast tissue, nipple, and a
  1.  ;;        small portion of the overlying skin, but lymph nodes and muscles are
  1.  ;;        left intact)
  1.  ;;                                               ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Modified radical mastectomy (For VA purposes, a modified radical
  1.  ;;        mastectomy means removal of the entire breast and axillary lymph nodes,
  1.  ;;        in continuity with the breast, with pectoral muscles left intact)
  1.  ;;                                               ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Radical mastectomy  (For VA purposes, radical mastectomy means removal
  1.  ;;        of the entire breast, underlying pectoral muscles, and regional lymph
  1.  ;;        nodes up to the coracoclavicular ligament)
  1.  ;;                                               ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Axillary or sentinel lymph node excision
  1.  ;;                                               ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Significant alteration of size or form
  1.  ;;                                               ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Biopsy                                 ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Other: _____________________           ___ Right   ___ Left   ___ Both
  1.  ;;^TOF^
  1.  ;; c. Are there any residual conditions caused by the benign or malignant
  1.  ;; neoplasm or its treatment (e.g., arm swelling, nerve damage to arm)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, briefly describe the conditions and complete appropriate
  1.  ;; Questionnaire: ______________________________________________________________
  1.  ;;
  1.  ;; 4. Objective findings and residuals
  1.  ;; Did the surgery or radiation treatment result in the loss of 25 percent or
  1.  ;; more tissue from a single breast or both breasts in combination?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; 5. 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 of
  1.  ;; all related scars greater than 39 square cm (6 square inches)?
  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 and/or symptoms related to any conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): ___________________________________________
  1.  ;;
  1.  ;; 6. Diagnostic testing
  1.  ;; NOTE: If imaging and/or diagnostic test results are in the medical record and
  1.  ;; reflect the Veteran's current condition, repeat testing is not required.
  1.  ;;
  1.  ;; Has the Veteran had imaging and/or diagnostic testing and if so, are there
  1.  ;; significant findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;;  ____________________________________________________________________________
  1.  ;;^TOF^
  1.  ;; 7. Functional impact
  1.  ;; Does the Veteran's breast condition(s) impact his or her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe impact of each of the Veteran's breast conditions, providing
  1.  ;; one or more examples: _______________________________________________________
  1.  ;;
  1.  ;; 8. 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