DVBCQBR2 ;;ALB-CIOFO/SBW - Breast Conditions and Disorders QUESTIONNAIRE ; 27/JUNE/2011
;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
;
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 had a disorder of the breast(s)?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to the breast(s):
;; 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 there are additional diagnoses that pertain to breast(s), list using above
;; format: _____________________________________________________________________
;;
;; 2. Medical history
;; a. Describe the history (including onset and course) of the Veteran's breast
;; condition: __________________________________________________________________
;;
;; b. Does the Veteran have, or have a history of, a neoplasm of the breast?
;; ___ Yes ___ No
;; If yes, is or was there a malignant neoplasm?
;; ___ Yes ___ No
;; If yes, ___ Right ___ Left ___ Both
;; If yes, were there or are there currently any metastases?
;; ___ Yes ___ No
;; If yes, describe locations: ___________________
;; If yes, is or was there a benign neoplasm?
;; ___ Yes ___ No
;; If yes, ___ Right ___ Left ___ Both
;;^TOF^
;; 3. Treatment/surgery
;; a. Has the Veteran completed any type of treatment or is the Veteran currently
;; undergoing treatment for a benign or malignant neoplasm and/or metastases?
;; ___ Yes ___ No; watchful waiting
;; If yes, indicate treatment type(s) (check all that apply):
;; ___ Treatment completed; currently in watchful waiting status
;; ___ Surgery
;; If checked, describe: ___________________
;; Date(s) of surgery: __________
;; ___ Radiation therapy
;; Date of most recent treatment: ___________
;; Date of completion of treatment or anticipated date of completion:
;; _________
;; Side: ___ Right ___ Left ___ Both
;; ___ Antineoplastic chemotherapy
;; Date of most recent treatment: ___________
;; Date of completion of treatment or anticipated date of completion:
;; _________
;; ___ Other therapeutic procedure and/or treatment
;; Date of most recent procedure: ___________
;; Date of completion of treatment or anticipated date of completion:
;; _________
;; Describe the other treatment and/or procedure: ______________________
;;
;; b. Has the Veteran undergone breast surgery?
;; ___ Yes ___ No
;; If yes, indicate procedure type and severity (check all that apply):
;; ___ Wide local excision (For VA purposes, wide local excision means
;; removal of a portion of the breast tissue and includes partial
;; mastectomy, lumpectomy, tylectomy, segmentectomy, and quadrantectomy)
;; ___ Right ___ Left ___ Both
;; ___ Simple (or total) mastectomy (For VA purposes, a simple (or total)
;; mastectomy means removal of all of the breast tissue, nipple, and a
;; small portion of the overlying skin, but lymph nodes and muscles are
;; left intact)
;; ___ Right ___ Left ___ Both
;; ___ Modified radical mastectomy (For VA purposes, a modified radical
;; mastectomy means removal of the entire breast and axillary lymph nodes,
;; in continuity with the breast, with pectoral muscles left intact)
;; ___ Right ___ Left ___ Both
;; ___ Radical mastectomy (For VA purposes, radical mastectomy means removal
;; of the entire breast, underlying pectoral muscles, and regional lymph
;; nodes up to the coracoclavicular ligament)
;; ___ Right ___ Left ___ Both
;; ___ Axillary or sentinel lymph node excision
;; ___ Right ___ Left ___ Both
;; ___ Significant alteration of size or form
;; ___ Right ___ Left ___ Both
;; ___ Biopsy ___ Right ___ Left ___ Both
;; ___ Other: _____________________ ___ Right ___ Left ___ Both
;;^TOF^
;; c. Are there any residual conditions caused by the benign or malignant
;; neoplasm or its treatment (e.g., arm swelling, nerve damage to arm)?
;; ___ Yes ___ No
;; If yes, briefly describe the conditions and complete appropriate
;; Questionnaire: ______________________________________________________________
;;
;; 4. Objective findings and residuals
;; Did the surgery or radiation treatment result in the loss of 25 percent or
;; more tissue from a single breast or both breasts in combination?
;; ___ Yes ___ No
;;
;; 5. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;; a. Does the Veteran have any scars (surgical or otherwise) related to any
;; conditions or to the treatment of any conditions listed in the Diagnosis
;; section above?
;; ___ Yes ___ No
;; If yes, are any of the scars painful and/or unstable, or is the total area of
;; all related scars greater than 39 square cm (6 square inches)?
;; ___ Yes ___ No
;; If yes, also complete a Scars Questionnaire.
;;
;; b. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs and/or symptoms related to any conditions
;; listed in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): ___________________________________________
;;
;; 6. Diagnostic testing
;; NOTE: If imaging and/or diagnostic test results are in the medical record and
;; reflect the Veteran's current condition, repeat testing is not required.
;;
;; Has the Veteran had imaging and/or diagnostic testing and if so, are there
;; significant findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;^TOF^
;; 7. Functional impact
;; Does the Veteran's breast condition(s) impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe impact of each of the Veteran's breast conditions, providing
;; one or more examples: _______________________________________________________
;;
;; 8. Remarks, if any: _________________________________________________________
;; _____________________________________________________________________________
;;
;; Physician signature: _______________________________________ Date: __________
;;
;; Physician printed name: _______________________________________
;;
;; Medical license #: _____________
;;
;; Physician address: ____________________________________________
;;
;; Phone: _________________________ Fax: _________________________
;;
;; 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[HDVBCQBR2 7858 printed Dec 13, 2024@01:45:52 Page 2
DVBCQBR2 ;;ALB-CIOFO/SBW - Breast Conditions and Disorders QUESTIONNAIRE ; 27/JUNE/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;;
+5 ;; 1. Diagnosis
+6 ;; Does the Veteran now have or has he/she ever had a disorder of the breast(s)?
+7 ;; ___ Yes ___ No
+8 ;;
+9 ;; If yes, provide only diagnoses that pertain to the breast(s):
+10 ;; Diagnosis #1: ____________________
+11 ;; ICD code: _____________________
+12 ;; Date of diagnosis #1: _______________
+13 ;;
+14 ;; Diagnosis #2: ____________________
+15 ;; ICD code: _____________________
+16 ;; Date of diagnosis #2: _______________
+17 ;;
+18 ;; Diagnosis #3: ____________________
+19 ;; ICD code: _____________________
+20 ;; Date of diagnosis #3: _______________
+21 ;;
+22 ;; If there are additional diagnoses that pertain to breast(s), list using above
+23 ;; format: _____________________________________________________________________
+24 ;;
+25 ;; 2. Medical history
+26 ;; a. Describe the history (including onset and course) of the Veteran's breast
+27 ;; condition: __________________________________________________________________
+28 ;;
+29 ;; b. Does the Veteran have, or have a history of, a neoplasm of the breast?
+30 ;; ___ Yes ___ No
+31 ;; If yes, is or was there a malignant neoplasm?
+32 ;; ___ Yes ___ No
+33 ;; If yes, ___ Right ___ Left ___ Both
+34 ;; If yes, were there or are there currently any metastases?
+35 ;; ___ Yes ___ No
+36 ;; If yes, describe locations: ___________________
+37 ;; If yes, is or was there a benign neoplasm?
+38 ;; ___ Yes ___ No
+39 ;; If yes, ___ Right ___ Left ___ Both
+40 ;;^TOF^
+41 ;; 3. Treatment/surgery
+42 ;; a. Has the Veteran completed any type of treatment or is the Veteran currently
+43 ;; undergoing treatment for a benign or malignant neoplasm and/or metastases?
+44 ;; ___ Yes ___ No; watchful waiting
+45 ;; If yes, indicate treatment type(s) (check all that apply):
+46 ;; ___ Treatment completed; currently in watchful waiting status
+47 ;; ___ Surgery
+48 ;; If checked, describe: ___________________
+49 ;; Date(s) of surgery: __________
+50 ;; ___ Radiation therapy
+51 ;; Date of most recent treatment: ___________
+52 ;; Date of completion of treatment or anticipated date of completion:
+53 ;; _________
+54 ;; Side: ___ Right ___ Left ___ Both
+55 ;; ___ Antineoplastic chemotherapy
+56 ;; Date of most recent treatment: ___________
+57 ;; Date of completion of treatment or anticipated date of completion:
+58 ;; _________
+59 ;; ___ Other therapeutic procedure and/or treatment
+60 ;; Date of most recent procedure: ___________
+61 ;; Date of completion of treatment or anticipated date of completion:
+62 ;; _________
+63 ;; Describe the other treatment and/or procedure: ______________________
+64 ;;
+65 ;; b. Has the Veteran undergone breast surgery?
+66 ;; ___ Yes ___ No
+67 ;; If yes, indicate procedure type and severity (check all that apply):
+68 ;; ___ Wide local excision (For VA purposes, wide local excision means
+69 ;; removal of a portion of the breast tissue and includes partial
+70 ;; mastectomy, lumpectomy, tylectomy, segmentectomy, and quadrantectomy)
+71 ;; ___ Right ___ Left ___ Both
+72 ;; ___ Simple (or total) mastectomy (For VA purposes, a simple (or total)
+73 ;; mastectomy means removal of all of the breast tissue, nipple, and a
+74 ;; small portion of the overlying skin, but lymph nodes and muscles are
+75 ;; left intact)
+76 ;; ___ Right ___ Left ___ Both
+77 ;; ___ Modified radical mastectomy (For VA purposes, a modified radical
+78 ;; mastectomy means removal of the entire breast and axillary lymph nodes,
+79 ;; in continuity with the breast, with pectoral muscles left intact)
+80 ;; ___ Right ___ Left ___ Both
+81 ;; ___ Radical mastectomy (For VA purposes, radical mastectomy means removal
+82 ;; of the entire breast, underlying pectoral muscles, and regional lymph
+83 ;; nodes up to the coracoclavicular ligament)
+84 ;; ___ Right ___ Left ___ Both
+85 ;; ___ Axillary or sentinel lymph node excision
+86 ;; ___ Right ___ Left ___ Both
+87 ;; ___ Significant alteration of size or form
+88 ;; ___ Right ___ Left ___ Both
+89 ;; ___ Biopsy ___ Right ___ Left ___ Both
+90 ;; ___ Other: _____________________ ___ Right ___ Left ___ Both
+91 ;;^TOF^
+92 ;; c. Are there any residual conditions caused by the benign or malignant
+93 ;; neoplasm or its treatment (e.g., arm swelling, nerve damage to arm)?
+94 ;; ___ Yes ___ No
+95 ;; If yes, briefly describe the conditions and complete appropriate
+96 ;; Questionnaire: ______________________________________________________________
+97 ;;
+98 ;; 4. Objective findings and residuals
+99 ;; Did the surgery or radiation treatment result in the loss of 25 percent or
+100 ;; more tissue from a single breast or both breasts in combination?
+101 ;; ___ Yes ___ No
+102 ;;
+103 ;; 5. Other pertinent physical findings, complications, conditions, signs
+104 ;; and/or symptoms
+105 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+106 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+107 ;; section above?
+108 ;; ___ Yes ___ No
+109 ;; If yes, are any of the scars painful and/or unstable, or is the total area of
+110 ;; all related scars greater than 39 square cm (6 square inches)?
+111 ;; ___ Yes ___ No
+112 ;; If yes, also complete a Scars Questionnaire.
+113 ;;
+114 ;; b. Does the Veteran have any other pertinent physical findings,
+115 ;; complications, conditions, signs and/or symptoms related to any conditions
+116 ;; listed in the Diagnosis section above?
+117 ;; ___ Yes ___ No
+118 ;; If yes, describe (brief summary): ___________________________________________
+119 ;;
+120 ;; 6. Diagnostic testing
+121 ;; NOTE: If imaging and/or diagnostic test results are in the medical record and
+122 ;; reflect the Veteran's current condition, repeat testing is not required.
+123 ;;
+124 ;; Has the Veteran had imaging and/or diagnostic testing and if so, are there
+125 ;; significant findings and/or results?
+126 ;; ___ Yes ___ No
+127 ;; If yes, provide type of test or procedure, date and results (brief summary):
+128 ;; ____________________________________________________________________________
+129 ;;^TOF^
+130 ;; 7. Functional impact
+131 ;; Does the Veteran's breast condition(s) impact his or her ability to work?
+132 ;; ___ Yes ___ No
+133 ;; If yes, describe impact of each of the Veteran's breast conditions, providing
+134 ;; one or more examples: _______________________________________________________
+135 ;;
+136 ;; 8. Remarks, if any: _________________________________________________________
+137 ;; _____________________________________________________________________________
+138 ;;
+139 ;; Physician signature: _______________________________________ Date: __________
+140 ;;
+141 ;; Physician printed name: _______________________________________
+142 ;;
+143 ;; Medical license #: _____________
+144 ;;
+145 ;; Physician address: ____________________________________________
+146 ;;
+147 ;; Phone: _________________________ Fax: _________________________
+148 ;;
+149 ;; NOTE: VA may request additional medical information, including additional
+150 ;; examinations if necessary to complete VA's review of the Veteran's application.
+151 ;;^END^
+152 QUIT
