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Routine: DVBCQDM2

DVBCQDM2.m

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  1. DVBCQDM2 ;;ALB-CIOFO/ECF - DIABETES MELLITUS QUESTIONNAIRE ; 6/15/2010
  1.  ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
  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.  ;; Select the Veteran's condition:
  1.  ;; ___ Diabetes mellitus type I   ICD code: _______  Date of diagnosis: _______
  1.  ;; ___ Diabetes mellitus type II  ICD code: _______  Date of diagnosis: _______
  1.  ;; ___ Impaired fasting glucose   ICD code: _______  Date of diagnosis: _______
  1.  ;; ___ Does not meet criteria for diagnosis of diabetes
  1.  ;; ___ Other (specify below), providing only diagnoses that pertain to DM or
  1.  ;;     its complications:
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; Diagnosis: _______________________
  1.  ;; ICD code: ________________________
  1.  ;; Date of diagnosis: _______________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to DM, list using above
  1.  ;; format: ____________________________________________________________________
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;;
  1.  ;; a. Treatment (check all that apply)
  1.  ;;    ___ None
  1.  ;;    ___ Managed by restricted diet
  1.  ;;    ___ Prescribed oral hypoglycemic agent(s)
  1.  ;;    ___ Prescribed insulin 1 injection per day
  1.  ;;    ___ Prescribed insulin more than 1 injection per day
  1.  ;;    ___ Other (describe): ______________________________
  1.  ;;
  1.  ;; b. Regulation of activities
  1.  ;;    Does the Veteran require regulation of activities as part of medical
  1.  ;;    management of diabetes mellitus (DM)?
  1.  ;;    ___ Yes   ___ No
  1.  ;;    If yes, provide one or more examples of how the Veteran must regulate his
  1.  ;;    or her activities: ______________________________________________________
  1.  ;;
  1.  ;;    NOTE: For VA purposes, regulation of activities can be defined as
  1.  ;;    avoidance of strenuous occupational and recreational activities with the
  1.  ;;    intention of avoiding hypoglycemic episodes.
  1.  ;;
  1.  ;; c. Frequency of diabetic care
  1.  ;;    How frequently does the Veteran visit his or her diabetic care provider
  1.  ;;    for episodes of ketoacidosis or hypoglycemic reactions?
  1.  ;;    ___ Less than 2 times per month   ___ 2 times per month   ___ Weekly
  1.  ;;^TOF^
  1.  ;; d. Hospitalizations for episodes of ketoacidosis or hypoglycemic reactions
  1.  ;;    How many episodes of ketoacidosis requiring hospitalization over the past
  1.  ;;    12 months?
  1.  ;;    ___ 0   ___ 1   ___ 2   ___ 3 or more
  1.  ;;
  1.  ;;    How many episodes of hypoglycemia requiring hospitalization over the past
  1.  ;;    12 months?
  1.  ;;    ___ 0   ___ 1   ___ 2   ___ 3 or more
  1.  ;;
  1.  ;; e. Loss of strength and weight
  1.  ;;    Has the Veteran had progressive unintentional weight loss attributable to
  1.  ;;    DM?
  1.  ;;    ___ Yes   ___ No
  1.  ;;
  1.  ;;    If yes, provide percent of loss of individual's baseline weight: _______%
  1.  ;;    NOTE: For VA purposes, "baseline weight" means the average weight for the
  1.  ;;    two-year-period preceding the onset of the disease.
  1.  ;;
  1.  ;;    Has the Veteran had progressive loss of strength attributable to DM?
  1.  ;;    ___ Yes   ___ No
  1.  ;;
  1.  ;; 3. Complications of DM
  1.  ;;
  1.  ;; a. Does the Veteran have any of the following recognized complications of DM?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, indicate the conditions below: (check all that apply)
  1.  ;;    ___ Diabetic peripheral neuropathy
  1.  ;;    ___ Diabetic nephropathy or renal dysfunction caused by DM
  1.  ;;    ___ Diabetic retinopathy
  1.  ;;
  1.  ;; For all checked boxes, also complete appropriate Questionnaire(s). (Eye
  1.  ;; Questionnaire must be completed by ophthalmologist or optometrist)
  1.  ;;^TOF^
  1.  ;; b. Does the Veteran have any of the following conditions that are at least
  1.  ;; as likely as not (at least a 50% probability) due to DM?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, indicate the conditions below: (check all that apply)
  1.  ;;   ___ Erectile dysfunction      If checked, also complete Male Reproductive
  1.  ;;                                 System Conditions Questionnaire.
  1.  ;;   ___ Cardiac condition(s)      If checked, also complete appropriate
  1.  ;;                                 cardiac Questionnaire (IHD or other cardiac
  1.  ;;                                 Questionnaire).
  1.  ;;   ___ Hypertension (in the presence of diabetic renal disease)
  1.  ;;                                 If checked, also complete Hypertension
  1.  ;;                                 Questionnaire.
  1.  ;;   ___ Peripheral vascular disease
  1.  ;;                                 If checked, also complete Arteries and
  1.  ;;                                 Veins Questionnaire.
  1.  ;;   ___ Stroke                    If checked, also complete appropriate
  1.  ;;                                 neurologic Questionnaire(s)
  1.  ;;                                 (Central Nervous System, Cranial nerves,
  1.  ;;                                 etc.).
  1.  ;;   ___ Skin condition(s)         If checked, also complete Skin
  1.  ;;                                 Questionnaire.
  1.  ;;   ___ Eye condition(s) other than diabetic retinopathy
  1.  ;;                                 ____________________________________________
  1.  ;;                                 If checked, also complete Eye Questionnaire.
  1.  ;;                                 (Eye Questionnaire must be completed by
  1.  ;;                                 ophthalmologist or optometrist)
  1.  ;;   ___ Other complications (describe): ______________________________________
  1.  ;;
  1.  ;; c. Has the Veteran's DM at least as likely as not (at least a 50%
  1.  ;; probability) permanently aggravated (meaning that any worsening of the
  1.  ;; condition is not due to natural progress) any of the following conditions?
  1.  ;; Check all that apply:
  1.  ;;   ___ Cardiac condition(s)     If checked, also complete appropriate
  1.  ;;                                cardiac Questionnaire (IHD or other cardiac
  1.  ;;                                Questionnaire).
  1.  ;;   ___ Hypertension             If checked, also complete Hypertension
  1.  ;;                                Questionnaire
  1.  ;;   ___ Renal disease            If checked, also complete Kidney
  1.  ;;                                Questionnaire
  1.  ;;   ___ Peripheral vascular disease
  1.  ;;                                If checked, also complete Arteries and
  1.  ;;                                Veins Questionnaire.
  1.  ;;   ___ Eye condition(s) other than diabetic retinopathy
  1.  ;;                               If checked, also complete Eye Questionnaire.
  1.  ;;                               (Eye Questionnaire must be completed by
  1.  ;;                               ophthalmologist or optometrist)
  1.  ;;   ___ Other permanently aggravated condition(s) (describe): ________________
  1.  ;;   ___ None
  1.  ;;^TOF^
  1.  ;; 4. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;;
  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
  1.  ;; of 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.  ;; 5. Diagnostic testing
  1.  ;;
  1.  ;; NOTE: If laboratory test results are in the medical record, repeat testing
  1.  ;; is not required.
  1.  ;; A glucose tolerance test is not required for VA purposes; report this test
  1.  ;; only if already completed.
  1.  ;;
  1.  ;; Test results used to make the diagnosis of DM (if known): (check all that
  1.  ;; apply)
  1.  ;;    ___ Fasting plasma glucose test (FPG)                Dates: _____________
  1.  ;;        of >= 126 mg/dl on 2 or more occasions
  1.  ;;    ___ A1C of 6.5% or greater on 2 or more occasions    Dates: _____________
  1.  ;;    ___ 2-hr plasma glucose of >= 200 mg/dl on glucose   Date: ______________
  1.  ;;        tolerance test
  1.  ;;    ___ Random plasma glucose of >= 200 mg/dl with       Date: ______________
  1.  ;;        classic symptoms of hyperglycemia
  1.  ;;    ___ Other, describe: ____________________________________________________
  1.  ;;
  1.  ;; Current test results:
  1.  ;;    Most recent A1C, if available: ______                Date: ______________
  1.  ;;    Most recent fasting plasma glucose,                  Date: ______________
  1.  ;;    if available: _______
  1.  ;;^TOF^
  1.  ;; 6. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's DM (and complications of DM if present) impact his or
  1.  ;; her ability to work? (Impact on ability to work may also be addressed on the
  1.  ;; individual Questionnaire(s) for other diabetes-associated conditions and/or
  1.  ;; complications, if completed.)
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, separately describe impact of the Veteran's DM, diabetes-associated
  1.  ;; conditions, and complications, if present, providing one or more examples:
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 7. Remarks, if any: ________________________________________________________
  1.  ;;
  1.  ;; Physician signature: ____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: _________________________________ Phone: ___________
  1.  ;;
  1.  ;; Medical license #: ______________________________________ Fax: _____________
  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.  ;;
  1.  ;;^END^
  1.  Q