DVBCQDM2 ;;ALB-CIOFO/ECF - DIABETES MELLITUS QUESTIONNAIRE ; 6/15/2010
;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
;
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
;;
;; Select the Veteran's condition:
;; ___ Diabetes mellitus type I ICD code: _______ Date of diagnosis: _______
;; ___ Diabetes mellitus type II ICD code: _______ Date of diagnosis: _______
;; ___ Impaired fasting glucose ICD code: _______ Date of diagnosis: _______
;; ___ Does not meet criteria for diagnosis of diabetes
;; ___ Other (specify below), providing only diagnoses that pertain to DM or
;; its complications:
;; ____________________________________________________________________________
;;
;; Diagnosis: _______________________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; If there are additional diagnoses that pertain to DM, list using above
;; format: ____________________________________________________________________
;;
;; 2. Medical history
;;
;; a. Treatment (check all that apply)
;; ___ None
;; ___ Managed by restricted diet
;; ___ Prescribed oral hypoglycemic agent(s)
;; ___ Prescribed insulin 1 injection per day
;; ___ Prescribed insulin more than 1 injection per day
;; ___ Other (describe): ______________________________
;;
;; b. Regulation of activities
;; Does the Veteran require regulation of activities as part of medical
;; management of diabetes mellitus (DM)?
;; ___ Yes ___ No
;; If yes, provide one or more examples of how the Veteran must regulate his
;; or her activities: ______________________________________________________
;;
;; NOTE: For VA purposes, regulation of activities can be defined as
;; avoidance of strenuous occupational and recreational activities with the
;; intention of avoiding hypoglycemic episodes.
;;
;; c. Frequency of diabetic care
;; How frequently does the Veteran visit his or her diabetic care provider
;; for episodes of ketoacidosis or hypoglycemic reactions?
;; ___ Less than 2 times per month ___ 2 times per month ___ Weekly
;;^TOF^
;; d. Hospitalizations for episodes of ketoacidosis or hypoglycemic reactions
;; How many episodes of ketoacidosis requiring hospitalization over the past
;; 12 months?
;; ___ 0 ___ 1 ___ 2 ___ 3 or more
;;
;; How many episodes of hypoglycemia requiring hospitalization over the past
;; 12 months?
;; ___ 0 ___ 1 ___ 2 ___ 3 or more
;;
;; e. Loss of strength and weight
;; Has the Veteran had progressive unintentional weight loss attributable to
;; DM?
;; ___ Yes ___ No
;;
;; If yes, provide percent of loss of individual's baseline weight: _______%
;; NOTE: For VA purposes, "baseline weight" means the average weight for the
;; two-year-period preceding the onset of the disease.
;;
;; Has the Veteran had progressive loss of strength attributable to DM?
;; ___ Yes ___ No
;;
;; 3. Complications of DM
;;
;; a. Does the Veteran have any of the following recognized complications of DM?
;; ___ Yes ___ No
;;
;; If yes, indicate the conditions below: (check all that apply)
;; ___ Diabetic peripheral neuropathy
;; ___ Diabetic nephropathy or renal dysfunction caused by DM
;; ___ Diabetic retinopathy
;;
;; For all checked boxes, also complete appropriate Questionnaire(s). (Eye
;; Questionnaire must be completed by ophthalmologist or optometrist)
;;^TOF^
;; b. Does the Veteran have any of the following conditions that are at least
;; as likely as not (at least a 50% probability) due to DM?
;; ___ Yes ___ No
;;
;; If yes, indicate the conditions below: (check all that apply)
;; ___ Erectile dysfunction If checked, also complete Male Reproductive
;; System Conditions Questionnaire.
;; ___ Cardiac condition(s) If checked, also complete appropriate
;; cardiac Questionnaire (IHD or other cardiac
;; Questionnaire).
;; ___ Hypertension (in the presence of diabetic renal disease)
;; If checked, also complete Hypertension
;; Questionnaire.
;; ___ Peripheral vascular disease
;; If checked, also complete Arteries and
;; Veins Questionnaire.
;; ___ Stroke If checked, also complete appropriate
;; neurologic Questionnaire(s)
;; (Central Nervous System, Cranial nerves,
;; etc.).
;; ___ Skin condition(s) If checked, also complete Skin
;; Questionnaire.
;; ___ Eye condition(s) other than diabetic retinopathy
;; ____________________________________________
;; If checked, also complete Eye Questionnaire.
;; (Eye Questionnaire must be completed by
;; ophthalmologist or optometrist)
;; ___ Other complications (describe): ______________________________________
;;
;; c. Has the Veteran's DM at least as likely as not (at least a 50%
;; probability) permanently aggravated (meaning that any worsening of the
;; condition is not due to natural progress) any of the following conditions?
;; Check all that apply:
;; ___ Cardiac condition(s) If checked, also complete appropriate
;; cardiac Questionnaire (IHD or other cardiac
;; Questionnaire).
;; ___ Hypertension If checked, also complete Hypertension
;; Questionnaire
;; ___ Renal disease If checked, also complete Kidney
;; Questionnaire
;; ___ Peripheral vascular disease
;; If checked, also complete Arteries and
;; Veins Questionnaire.
;; ___ Eye condition(s) other than diabetic retinopathy
;; If checked, also complete Eye Questionnaire.
;; (Eye Questionnaire must be completed by
;; ophthalmologist or optometrist)
;; ___ Other permanently aggravated condition(s) (describe): ________________
;; ___ None
;;^TOF^
;; 4. 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): __________________________________________
;;
;; 5. Diagnostic testing
;;
;; NOTE: If laboratory test results are in the medical record, repeat testing
;; is not required.
;; A glucose tolerance test is not required for VA purposes; report this test
;; only if already completed.
;;
;; Test results used to make the diagnosis of DM (if known): (check all that
;; apply)
;; ___ Fasting plasma glucose test (FPG) Dates: _____________
;; of >= 126 mg/dl on 2 or more occasions
;; ___ A1C of 6.5% or greater on 2 or more occasions Dates: _____________
;; ___ 2-hr plasma glucose of >= 200 mg/dl on glucose Date: ______________
;; tolerance test
;; ___ Random plasma glucose of >= 200 mg/dl with Date: ______________
;; classic symptoms of hyperglycemia
;; ___ Other, describe: ____________________________________________________
;;
;; Current test results:
;; Most recent A1C, if available: ______ Date: ______________
;; Most recent fasting plasma glucose, Date: ______________
;; if available: _______
;;^TOF^
;; 6. Functional impact
;;
;; Does the Veteran's DM (and complications of DM if present) impact his or
;; her ability to work? (Impact on ability to work may also be addressed on the
;; individual Questionnaire(s) for other diabetes-associated conditions and/or
;; complications, if completed.)
;; ___ Yes ___ No
;;
;; If yes, separately describe impact of the Veteran's DM, diabetes-associated
;; conditions, and complications, if present, providing one or more examples:
;; ____________________________________________________________________________
;;
;; 7. Remarks, if any: ________________________________________________________
;;
;; Physician signature: ____________________________________ Date: ____________
;;
;; Physician printed name: _________________________________ Phone: ___________
;;
;; Medical license #: ______________________________________ Fax: _____________
;;
;; 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[HDVBCQDM2 10038 printed Oct 16, 2024@17:46:47 Page 2
DVBCQDM2 ;;ALB-CIOFO/ECF - DIABETES MELLITUS QUESTIONNAIRE ; 6/15/2010
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+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 ;; Select the Veteran's condition:
+10 ;; ___ Diabetes mellitus type I ICD code: _______ Date of diagnosis: _______
+11 ;; ___ Diabetes mellitus type II ICD code: _______ Date of diagnosis: _______
+12 ;; ___ Impaired fasting glucose ICD code: _______ Date of diagnosis: _______
+13 ;; ___ Does not meet criteria for diagnosis of diabetes
+14 ;; ___ Other (specify below), providing only diagnoses that pertain to DM or
+15 ;; its complications:
+16 ;; ____________________________________________________________________________
+17 ;;
+18 ;; Diagnosis: _______________________
+19 ;; ICD code: ________________________
+20 ;; Date of diagnosis: _______________
+21 ;;
+22 ;; If there are additional diagnoses that pertain to DM, list using above
+23 ;; format: ____________________________________________________________________
+24 ;;
+25 ;; 2. Medical history
+26 ;;
+27 ;; a. Treatment (check all that apply)
+28 ;; ___ None
+29 ;; ___ Managed by restricted diet
+30 ;; ___ Prescribed oral hypoglycemic agent(s)
+31 ;; ___ Prescribed insulin 1 injection per day
+32 ;; ___ Prescribed insulin more than 1 injection per day
+33 ;; ___ Other (describe): ______________________________
+34 ;;
+35 ;; b. Regulation of activities
+36 ;; Does the Veteran require regulation of activities as part of medical
+37 ;; management of diabetes mellitus (DM)?
+38 ;; ___ Yes ___ No
+39 ;; If yes, provide one or more examples of how the Veteran must regulate his
+40 ;; or her activities: ______________________________________________________
+41 ;;
+42 ;; NOTE: For VA purposes, regulation of activities can be defined as
+43 ;; avoidance of strenuous occupational and recreational activities with the
+44 ;; intention of avoiding hypoglycemic episodes.
+45 ;;
+46 ;; c. Frequency of diabetic care
+47 ;; How frequently does the Veteran visit his or her diabetic care provider
+48 ;; for episodes of ketoacidosis or hypoglycemic reactions?
+49 ;; ___ Less than 2 times per month ___ 2 times per month ___ Weekly
+50 ;;^TOF^
+51 ;; d. Hospitalizations for episodes of ketoacidosis or hypoglycemic reactions
+52 ;; How many episodes of ketoacidosis requiring hospitalization over the past
+53 ;; 12 months?
+54 ;; ___ 0 ___ 1 ___ 2 ___ 3 or more
+55 ;;
+56 ;; How many episodes of hypoglycemia requiring hospitalization over the past
+57 ;; 12 months?
+58 ;; ___ 0 ___ 1 ___ 2 ___ 3 or more
+59 ;;
+60 ;; e. Loss of strength and weight
+61 ;; Has the Veteran had progressive unintentional weight loss attributable to
+62 ;; DM?
+63 ;; ___ Yes ___ No
+64 ;;
+65 ;; If yes, provide percent of loss of individual's baseline weight: _______%
+66 ;; NOTE: For VA purposes, "baseline weight" means the average weight for the
+67 ;; two-year-period preceding the onset of the disease.
+68 ;;
+69 ;; Has the Veteran had progressive loss of strength attributable to DM?
+70 ;; ___ Yes ___ No
+71 ;;
+72 ;; 3. Complications of DM
+73 ;;
+74 ;; a. Does the Veteran have any of the following recognized complications of DM?
+75 ;; ___ Yes ___ No
+76 ;;
+77 ;; If yes, indicate the conditions below: (check all that apply)
+78 ;; ___ Diabetic peripheral neuropathy
+79 ;; ___ Diabetic nephropathy or renal dysfunction caused by DM
+80 ;; ___ Diabetic retinopathy
+81 ;;
+82 ;; For all checked boxes, also complete appropriate Questionnaire(s). (Eye
+83 ;; Questionnaire must be completed by ophthalmologist or optometrist)
+84 ;;^TOF^
+85 ;; b. Does the Veteran have any of the following conditions that are at least
+86 ;; as likely as not (at least a 50% probability) due to DM?
+87 ;; ___ Yes ___ No
+88 ;;
+89 ;; If yes, indicate the conditions below: (check all that apply)
+90 ;; ___ Erectile dysfunction If checked, also complete Male Reproductive
+91 ;; System Conditions Questionnaire.
+92 ;; ___ Cardiac condition(s) If checked, also complete appropriate
+93 ;; cardiac Questionnaire (IHD or other cardiac
+94 ;; Questionnaire).
+95 ;; ___ Hypertension (in the presence of diabetic renal disease)
+96 ;; If checked, also complete Hypertension
+97 ;; Questionnaire.
+98 ;; ___ Peripheral vascular disease
+99 ;; If checked, also complete Arteries and
+100 ;; Veins Questionnaire.
+101 ;; ___ Stroke If checked, also complete appropriate
+102 ;; neurologic Questionnaire(s)
+103 ;; (Central Nervous System, Cranial nerves,
+104 ;; etc.).
+105 ;; ___ Skin condition(s) If checked, also complete Skin
+106 ;; Questionnaire.
+107 ;; ___ Eye condition(s) other than diabetic retinopathy
+108 ;; ____________________________________________
+109 ;; If checked, also complete Eye Questionnaire.
+110 ;; (Eye Questionnaire must be completed by
+111 ;; ophthalmologist or optometrist)
+112 ;; ___ Other complications (describe): ______________________________________
+113 ;;
+114 ;; c. Has the Veteran's DM at least as likely as not (at least a 50%
+115 ;; probability) permanently aggravated (meaning that any worsening of the
+116 ;; condition is not due to natural progress) any of the following conditions?
+117 ;; Check all that apply:
+118 ;; ___ Cardiac condition(s) If checked, also complete appropriate
+119 ;; cardiac Questionnaire (IHD or other cardiac
+120 ;; Questionnaire).
+121 ;; ___ Hypertension If checked, also complete Hypertension
+122 ;; Questionnaire
+123 ;; ___ Renal disease If checked, also complete Kidney
+124 ;; Questionnaire
+125 ;; ___ Peripheral vascular disease
+126 ;; If checked, also complete Arteries and
+127 ;; Veins Questionnaire.
+128 ;; ___ Eye condition(s) other than diabetic retinopathy
+129 ;; If checked, also complete Eye Questionnaire.
+130 ;; (Eye Questionnaire must be completed by
+131 ;; ophthalmologist or optometrist)
+132 ;; ___ Other permanently aggravated condition(s) (describe): ________________
+133 ;; ___ None
+134 ;;^TOF^
+135 ;; 4. Other pertinent physical findings, complications, conditions, signs
+136 ;; and/or symptoms
+137 ;;
+138 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+139 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+140 ;; section above?
+141 ;; ___ Yes ___ No
+142 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+143 ;; of all related scars greater than 39 square cm (6 square inches)?
+144 ;; ___ Yes ___ No
+145 ;; If yes, also complete a Scars Questionnaire.
+146 ;;
+147 ;; b. Does the Veteran have any other pertinent physical findings,
+148 ;; complications, conditions, signs and/or symptoms related to any conditions
+149 ;; listed in the Diagnosis section above?
+150 ;; ___ Yes ___ No
+151 ;; If yes, describe (brief summary): __________________________________________
+152 ;;
+153 ;; 5. Diagnostic testing
+154 ;;
+155 ;; NOTE: If laboratory test results are in the medical record, repeat testing
+156 ;; is not required.
+157 ;; A glucose tolerance test is not required for VA purposes; report this test
+158 ;; only if already completed.
+159 ;;
+160 ;; Test results used to make the diagnosis of DM (if known): (check all that
+161 ;; apply)
+162 ;; ___ Fasting plasma glucose test (FPG) Dates: _____________
+163 ;; of >= 126 mg/dl on 2 or more occasions
+164 ;; ___ A1C of 6.5% or greater on 2 or more occasions Dates: _____________
+165 ;; ___ 2-hr plasma glucose of >= 200 mg/dl on glucose Date: ______________
+166 ;; tolerance test
+167 ;; ___ Random plasma glucose of >= 200 mg/dl with Date: ______________
+168 ;; classic symptoms of hyperglycemia
+169 ;; ___ Other, describe: ____________________________________________________
+170 ;;
+171 ;; Current test results:
+172 ;; Most recent A1C, if available: ______ Date: ______________
+173 ;; Most recent fasting plasma glucose, Date: ______________
+174 ;; if available: _______
+175 ;;^TOF^
+176 ;; 6. Functional impact
+177 ;;
+178 ;; Does the Veteran's DM (and complications of DM if present) impact his or
+179 ;; her ability to work? (Impact on ability to work may also be addressed on the
+180 ;; individual Questionnaire(s) for other diabetes-associated conditions and/or
+181 ;; complications, if completed.)
+182 ;; ___ Yes ___ No
+183 ;;
+184 ;; If yes, separately describe impact of the Veteran's DM, diabetes-associated
+185 ;; conditions, and complications, if present, providing one or more examples:
+186 ;; ____________________________________________________________________________
+187 ;;
+188 ;; 7. Remarks, if any: ________________________________________________________
+189 ;;
+190 ;; Physician signature: ____________________________________ Date: ____________
+191 ;;
+192 ;; Physician printed name: _________________________________ Phone: ___________
+193 ;;
+194 ;; Medical license #: ______________________________________ Fax: _____________
+195 ;;
+196 ;; Physician address: _________________________________________________________
+197 ;;
+198 ;; NOTE: VA may request additional medical information, including additional
+199 ;; examinations if necessary to complete VA's review of the Veteran's
+200 ;; application.
+201 ;;
+202 ;;^END^
+203 QUIT
