DVBCQED2 ;;ALB-CIOFO/ECF - EAR DISEASE (Inc Vestibular and Inf Condns) QUESTIONNAIRE ; 6/20/2010
;;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 been diagnosed with an ear or
;; peripheral vestibular condition?
;; ___ Yes ___ No
;;
;; If yes, select the Veteran's condition (check all that apply):
;; ___ Meniere's syndrome or ICD code: ______ Date of diagnosis: _________
;; endolymphatic hydrops
;; ___ Peripheral vestibular ICD code: ______ Date of diagnosis: _________
;; disorder
;; ___ Benign Paroxysmal ICD code: ______ Date of diagnosis: _________
;; Positional Vertigo (BPPV)
;; ___ Chronic otitis externa ICD code: ______ Date of diagnosis: _________
;; ___ Chronic suppurative ICD code: ______ Date of diagnosis: _________
;; otitis media
;; ___ Chronic nonsuppurative ICD code: ______ Date of diagnosis: _________
;; otitis media (serous otitis media)
;; ___ Mastoiditis ICD code: ______ Date of diagnosis: _________
;; ___ Cholesteatoma ICD code: ______ Date of diagnosis: _________
;; If checked, a Hearing Loss and Tinnitus Questionnaire must ALSO
;; be completed.
;; ___ Otosclerosis ICD code: ______ Date of diagnosis: _________
;; If checked, a Hearing Loss and Tinnitus Questionnaire must be completed
;; in lieu of this Questionnaire.
;; ___ Benign neoplasm of the ICD code: ______ Date of diagnosis: _________
;; ear (other than skin only)
;; ___ Malignant neoplasm of ICD code: ______ Date of diagnosis: _________
;; the ear (other than skin only)
;; ___ Other, specify:
;;
;; Other diagnosis #1: ______________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; Other diagnosis #2: ______________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; If there are additional diagnoses that pertain to ear or peripheral
;; vestibular conditions, list using above format: ____________________________
;;
;; NOTE: If the Veteran has hearing loss or tinnitus attributable to any ear
;; condition listed above, a Hearing Loss and Tinnitus Questionnaire must ALSO
;; be completed.
;;^TOF^
;; 2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's ear
;; or peripheral vestibular conditions (brief summary): _______________________
;;
;; b. Does the Veteran's treatment plan include taking continuous medication
;; for the diagnosed condition?
;; ___ Yes ___ No
;; If yes, list only those medications used for the diagnosed condition:
;; ____________________________________________________________________________
;;
;; 3. Vestibular conditions
;;
;; Does the Veteran have any of the following findings, signs or symptoms
;; attributable to Meniere's syndrome (endolymphatic hydrops), a peripheral
;; vestibular condition or another diagnosed condition from Section 1?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Hearing impairment with vertigo
;; If checked, indicate frequency:
;; ___ Less than once a month
;; ___ 1 to 4 times per month
;; ___ More than once weekly
;; Indicate duration of episodes:
;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
;; ___ Hearing impairment with attacks of vertigo and cerebellar gait
;; If checked, indicate frequency:
;; ___ Less than once a month
;; ___ 1 to 4 times per month
;; ___ More than once weekly
;; Indicate duration of episodes:
;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
;; ___ Tinnitus, unilateral or bilateral
;; If checked, indicate frequency:
;; ___ Less than once a month
;; ___ 1 to 4 times per month
;; ___ More than once weekly
;; Indicate duration of episodes:
;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
;; ___ Vertigo
;; If checked, indicate frequency:
;; ___ Less than once a month
;; ___ 1 to 4 times per month
;; ___ More than once weekly
;; Indicate duration of episodes:
;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
;;^TOF^
;; ___ Staggering
;; If checked, indicate frequency:
;; ___ Less than once a month
;; ___ 1 to 4 times per month
;; ___ More than once weekly
;; Indicate duration of episodes:
;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
;; ___ Hearing impairment and/or tinnitus
;; If checked, a Hearing Loss and Tinnitus Questionnaire must ALSO be
;; completed.
;; ___ Other, describe: _______________________________________________________
;;
;; 4. Infectious, inflammatory and other ear conditions
;;
;; a. Does the Veteran have any of the following findings, signs or symptoms
;; attributable to chronic ear infection, inflammation, cholesteatoma or any
;; of the diagnoses in Section 1?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Swelling (external ear canal)
;; If checked, describe: _______________________________________________
;; ___ Dry and scaly (external ear canal)
;; ___ Serous discharge (external ear canal)
;; ___ Itching (external ear canal)
;; ___ Effusion
;; ___ Active suppuration
;; ___ Aural polyps
;; ___ Hearing impairment and/or tinnitus
;; If checked, a Hearing Loss and Tinnitus Questionnaire must ALSO be
;; completed.
;; ___ Facial nerve paralysis
;; If checked, ALSO complete Cranial Nerves Questionnaire.
;; ___ Bone loss of skull
;; If checked, indicate severity:
;; ___ Area lost smaller than an American quarter (4.619 cm2)
;; ___ Area lost larger than an American quarter but smaller than a
;; 50-cent piece
;; ___ Area lost larger than an American 50-cent piece (7.355 cm2)
;; ___ Requiring frequent and prolonged treatment
;; If checked, describe type and durations of treatment: __________________
;; ___ Other, describe: _______________________________________________________
;;
;; b. Does the Veteran have a benign neoplasm of the ear (other than skin only,
;; such as keloid) that causes any impairment of function?
;; ___ Yes ___ No
;; If yes, describe impairment of function caused by this condition: __________
;;
;; ____________________________________________________________________________
;;^TOF^
;; 5. Surgical treatment
;;
;; a. Has the Veteran had surgical treatment for any ear condition?
;; ___ Yes ___ No
;; If yes, indicate type of surgery: __________________________________________
;; Date: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; b. Does the Veteran have any residuals as a result of the surgery?
;; ___ Yes ___ No
;; If yes, describe: __________________________________________________________
;;
;; 6. Physical exam
;;
;; a. External ear
;; ___ Exam of external ear not indicated
;; ___ Normal
;; ___ Deformity of auricle, with loss of less than one-third of the
;; substance
;; If checked, specify side: ___ Right ___ Left
;; ___ Deformity of auricle, with loss of one-third or more of the substance
;; If checked, specify side: ___ Right ___ Left
;; ___ Complete loss of auricle
;; If checked, specify side: ___ Right ___ Left
;; ___ Other abnormality, describe: __________________________________________
;;
;; b. Ear canal:
;; ___ Exam of ear canal not indicated
;; ___ Normal
;; ___ Abnormal, describe: ____________________________________________________
;;
;; c. Tympanic membrane:
;; ___ Exam of tympanic membrane not indicated
;; ___ Normal
;; ___ Perforated tympanic membrane
;; If checked, specify side affected: ___ Right ___ Left
;; ___ Evidence of a healed tympanic membrane perforation
;; If checked, specify side affected: ___ Right ___ Left
;; ___ Other abnormality, describe: ___________________________________________
;;
;; d. Gait:
;; ___ Exam of gait not indicated
;; ___ Normal
;; ___ Unsteady, describe: ____________________________________________________
;; ___ Other abnormality, describe: ___________________________________________
;;^TOF^
;; e. Romberg test:
;; ___ Exam using this test not indicated
;; ___ Normal or negative
;; ___ Abnormal or positive for unsteadiness
;;
;; f. Dix Hallpike test (Nylen-Barany test) for vertigo
;; ___ Exam using this test not indicated
;; ___ Normal, no vertigo or nystagmus during test
;; ___ Abnormal, vertigo or nystagmus during test, describe: __________________
;;
;; g. Limb coordination test (finger-nose-finger)
;; ___ Exam using this test not indicated
;; ___ Normal
;; ___ Abnormal, describe: ____________________________________________________
;;
;; 7. Tumors and neoplasms
;;
;; a. Does the Veteran have a benign or malignant neoplasm or metastases
;; related to any of the diagnoses in the Diagnosis section?
;; ___ Yes ___ No
;; If yes, complete the following:
;;
;; b. Is the neoplasm
;; ___ Benign ___ Malignant
;;
;; c. Has the Veteran completed treatment or is the Veteran currently
;; undergoing treatment for a benign or malignant neoplasm or metastases?
;; ___ Yes ___ No; watchful waiting
;; If yes, indicate type of treatment the Veteran is currently undergoing or
;; has completed (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: _____
;; ___ Antineoplastic chemotherapy
;; Date of most recent treatment: ___________
;; Date of completion of treatment or anticipated date of completion: _____
;; ___ Other therapeutic procedure
;; If checked, describe procedure: ________________________________________
;; Date of most recent procedure: ___________
;; ___ Other therapeutic treatment
;; If checked, describe treatment: ________________________________________
;; Date of completion of treatment or anticipated date of completion:
;; ___________________
;;^TOF^
;; d. Does the Veteran currently have any residual conditions or complications
;; due to the neoplasm (including metastases) or its treatment, other than
;; those already documented in the report above?
;; ___ Yes ___ No
;; If yes, list residual conditions and complications (brief summary): ________
;;
;; e. If there are additional benign or malignant neoplasms or metastases
;; related to any of the diagnoses in the Diagnosis section, describe using the
;; above format: ______________________________________________________________
;;
;; 8. 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
;; in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): __________________________________________
;;
;; 9. Diagnostic testing
;;
;; NOTE: If testing has been performed and reflects Veteran's current
;; condition, no further testing is required for this examination report.
;;
;; a. Have diagnostic imaging studies or other diagnostic procedures been
;; performed?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Magnetic resonance imaging (MRI)
;; Date: ___________ Results: _______________
;; ___ Computerized axial tomography (CT)
;; Date: ___________ Results: ______________
;; ___ Electronystagmography (ENG)
;; Date: ___________ Results: ______________
;; ___ Other, specify: __________________________
;; Date: ___________ Results: ______________
;;^TOF^
;; b. Has the Veteran had an audiogram?
;; ___ Yes ___ No
;; If yes, attach or provide results: _________________________________________
;; If the Veteran has hearing loss or tinnitus, a Hearing and Tinnitus exam
;; must ALSO be scheduled.
;;
;; c. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;
;; 10. Functional impact
;;
;; Do any of the Veteran's ear or peripheral vestibular conditions impact his
;; or her ability to work?
;; ___ Yes ___ No
;; If yes, describe impact of each of the Veteran's ear or peripheral
;; vestibular conditions, providing one or more examples: _____________________
;;
;;_____________________________________________________________________________
;;
;; 11. 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[HDVBCQED2 14563 printed Apr 09, 2024@20:55:25 Page 2
DVBCQED2 ;;ALB-CIOFO/ECF - EAR DISEASE (Inc Vestibular and Inf Condns) QUESTIONNAIRE ; 6/20/2010
+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 ;;
+7 ;; Does the Veteran now have or has he/she ever been diagnosed with an ear or
+8 ;; peripheral vestibular condition?
+9 ;; ___ Yes ___ No
+10 ;;
+11 ;; If yes, select the Veteran's condition (check all that apply):
+12 ;; ___ Meniere's syndrome or ICD code: ______ Date of diagnosis: _________
+13 ;; endolymphatic hydrops
+14 ;; ___ Peripheral vestibular ICD code: ______ Date of diagnosis: _________
+15 ;; disorder
+16 ;; ___ Benign Paroxysmal ICD code: ______ Date of diagnosis: _________
+17 ;; Positional Vertigo (BPPV)
+18 ;; ___ Chronic otitis externa ICD code: ______ Date of diagnosis: _________
+19 ;; ___ Chronic suppurative ICD code: ______ Date of diagnosis: _________
+20 ;; otitis media
+21 ;; ___ Chronic nonsuppurative ICD code: ______ Date of diagnosis: _________
+22 ;; otitis media (serous otitis media)
+23 ;; ___ Mastoiditis ICD code: ______ Date of diagnosis: _________
+24 ;; ___ Cholesteatoma ICD code: ______ Date of diagnosis: _________
+25 ;; If checked, a Hearing Loss and Tinnitus Questionnaire must ALSO
+26 ;; be completed.
+27 ;; ___ Otosclerosis ICD code: ______ Date of diagnosis: _________
+28 ;; If checked, a Hearing Loss and Tinnitus Questionnaire must be completed
+29 ;; in lieu of this Questionnaire.
+30 ;; ___ Benign neoplasm of the ICD code: ______ Date of diagnosis: _________
+31 ;; ear (other than skin only)
+32 ;; ___ Malignant neoplasm of ICD code: ______ Date of diagnosis: _________
+33 ;; the ear (other than skin only)
+34 ;; ___ Other, specify:
+35 ;;
+36 ;; Other diagnosis #1: ______________
+37 ;; ICD code: ________________________
+38 ;; Date of diagnosis: _______________
+39 ;;
+40 ;; Other diagnosis #2: ______________
+41 ;; ICD code: ________________________
+42 ;; Date of diagnosis: _______________
+43 ;;
+44 ;; If there are additional diagnoses that pertain to ear or peripheral
+45 ;; vestibular conditions, list using above format: ____________________________
+46 ;;
+47 ;; NOTE: If the Veteran has hearing loss or tinnitus attributable to any ear
+48 ;; condition listed above, a Hearing Loss and Tinnitus Questionnaire must ALSO
+49 ;; be completed.
+50 ;;^TOF^
+51 ;; 2. Medical history
+52 ;;
+53 ;; a. Describe the history (including onset and course) of the Veteran's ear
+54 ;; or peripheral vestibular conditions (brief summary): _______________________
+55 ;;
+56 ;; b. Does the Veteran's treatment plan include taking continuous medication
+57 ;; for the diagnosed condition?
+58 ;; ___ Yes ___ No
+59 ;; If yes, list only those medications used for the diagnosed condition:
+60 ;; ____________________________________________________________________________
+61 ;;
+62 ;; 3. Vestibular conditions
+63 ;;
+64 ;; Does the Veteran have any of the following findings, signs or symptoms
+65 ;; attributable to Meniere's syndrome (endolymphatic hydrops), a peripheral
+66 ;; vestibular condition or another diagnosed condition from Section 1?
+67 ;; ___ Yes ___ No
+68 ;; If yes, check all that apply:
+69 ;; ___ Hearing impairment with vertigo
+70 ;; If checked, indicate frequency:
+71 ;; ___ Less than once a month
+72 ;; ___ 1 to 4 times per month
+73 ;; ___ More than once weekly
+74 ;; Indicate duration of episodes:
+75 ;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
+76 ;; ___ Hearing impairment with attacks of vertigo and cerebellar gait
+77 ;; If checked, indicate frequency:
+78 ;; ___ Less than once a month
+79 ;; ___ 1 to 4 times per month
+80 ;; ___ More than once weekly
+81 ;; Indicate duration of episodes:
+82 ;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
+83 ;; ___ Tinnitus, unilateral or bilateral
+84 ;; If checked, indicate frequency:
+85 ;; ___ Less than once a month
+86 ;; ___ 1 to 4 times per month
+87 ;; ___ More than once weekly
+88 ;; Indicate duration of episodes:
+89 ;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
+90 ;; ___ Vertigo
+91 ;; If checked, indicate frequency:
+92 ;; ___ Less than once a month
+93 ;; ___ 1 to 4 times per month
+94 ;; ___ More than once weekly
+95 ;; Indicate duration of episodes:
+96 ;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
+97 ;;^TOF^
+98 ;; ___ Staggering
+99 ;; If checked, indicate frequency:
+100 ;; ___ Less than once a month
+101 ;; ___ 1 to 4 times per month
+102 ;; ___ More than once weekly
+103 ;; Indicate duration of episodes:
+104 ;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
+105 ;; ___ Hearing impairment and/or tinnitus
+106 ;; If checked, a Hearing Loss and Tinnitus Questionnaire must ALSO be
+107 ;; completed.
+108 ;; ___ Other, describe: _______________________________________________________
+109 ;;
+110 ;; 4. Infectious, inflammatory and other ear conditions
+111 ;;
+112 ;; a. Does the Veteran have any of the following findings, signs or symptoms
+113 ;; attributable to chronic ear infection, inflammation, cholesteatoma or any
+114 ;; of the diagnoses in Section 1?
+115 ;; ___ Yes ___ No
+116 ;; If yes, check all that apply:
+117 ;; ___ Swelling (external ear canal)
+118 ;; If checked, describe: _______________________________________________
+119 ;; ___ Dry and scaly (external ear canal)
+120 ;; ___ Serous discharge (external ear canal)
+121 ;; ___ Itching (external ear canal)
+122 ;; ___ Effusion
+123 ;; ___ Active suppuration
+124 ;; ___ Aural polyps
+125 ;; ___ Hearing impairment and/or tinnitus
+126 ;; If checked, a Hearing Loss and Tinnitus Questionnaire must ALSO be
+127 ;; completed.
+128 ;; ___ Facial nerve paralysis
+129 ;; If checked, ALSO complete Cranial Nerves Questionnaire.
+130 ;; ___ Bone loss of skull
+131 ;; If checked, indicate severity:
+132 ;; ___ Area lost smaller than an American quarter (4.619 cm2)
+133 ;; ___ Area lost larger than an American quarter but smaller than a
+134 ;; 50-cent piece
+135 ;; ___ Area lost larger than an American 50-cent piece (7.355 cm2)
+136 ;; ___ Requiring frequent and prolonged treatment
+137 ;; If checked, describe type and durations of treatment: __________________
+138 ;; ___ Other, describe: _______________________________________________________
+139 ;;
+140 ;; b. Does the Veteran have a benign neoplasm of the ear (other than skin only,
+141 ;; such as keloid) that causes any impairment of function?
+142 ;; ___ Yes ___ No
+143 ;; If yes, describe impairment of function caused by this condition: __________
+144 ;;
+145 ;; ____________________________________________________________________________
+146 ;;^TOF^
+147 ;; 5. Surgical treatment
+148 ;;
+149 ;; a. Has the Veteran had surgical treatment for any ear condition?
+150 ;; ___ Yes ___ No
+151 ;; If yes, indicate type of surgery: __________________________________________
+152 ;; Date: ______________
+153 ;; Side affected: ___ Right ___ Left ___ Both
+154 ;;
+155 ;; b. Does the Veteran have any residuals as a result of the surgery?
+156 ;; ___ Yes ___ No
+157 ;; If yes, describe: __________________________________________________________
+158 ;;
+159 ;; 6. Physical exam
+160 ;;
+161 ;; a. External ear
+162 ;; ___ Exam of external ear not indicated
+163 ;; ___ Normal
+164 ;; ___ Deformity of auricle, with loss of less than one-third of the
+165 ;; substance
+166 ;; If checked, specify side: ___ Right ___ Left
+167 ;; ___ Deformity of auricle, with loss of one-third or more of the substance
+168 ;; If checked, specify side: ___ Right ___ Left
+169 ;; ___ Complete loss of auricle
+170 ;; If checked, specify side: ___ Right ___ Left
+171 ;; ___ Other abnormality, describe: __________________________________________
+172 ;;
+173 ;; b. Ear canal:
+174 ;; ___ Exam of ear canal not indicated
+175 ;; ___ Normal
+176 ;; ___ Abnormal, describe: ____________________________________________________
+177 ;;
+178 ;; c. Tympanic membrane:
+179 ;; ___ Exam of tympanic membrane not indicated
+180 ;; ___ Normal
+181 ;; ___ Perforated tympanic membrane
+182 ;; If checked, specify side affected: ___ Right ___ Left
+183 ;; ___ Evidence of a healed tympanic membrane perforation
+184 ;; If checked, specify side affected: ___ Right ___ Left
+185 ;; ___ Other abnormality, describe: ___________________________________________
+186 ;;
+187 ;; d. Gait:
+188 ;; ___ Exam of gait not indicated
+189 ;; ___ Normal
+190 ;; ___ Unsteady, describe: ____________________________________________________
+191 ;; ___ Other abnormality, describe: ___________________________________________
+192 ;;^TOF^
+193 ;; e. Romberg test:
+194 ;; ___ Exam using this test not indicated
+195 ;; ___ Normal or negative
+196 ;; ___ Abnormal or positive for unsteadiness
+197 ;;
+198 ;; f. Dix Hallpike test (Nylen-Barany test) for vertigo
+199 ;; ___ Exam using this test not indicated
+200 ;; ___ Normal, no vertigo or nystagmus during test
+201 ;; ___ Abnormal, vertigo or nystagmus during test, describe: __________________
+202 ;;
+203 ;; g. Limb coordination test (finger-nose-finger)
+204 ;; ___ Exam using this test not indicated
+205 ;; ___ Normal
+206 ;; ___ Abnormal, describe: ____________________________________________________
+207 ;;
+208 ;; 7. Tumors and neoplasms
+209 ;;
+210 ;; a. Does the Veteran have a benign or malignant neoplasm or metastases
+211 ;; related to any of the diagnoses in the Diagnosis section?
+212 ;; ___ Yes ___ No
+213 ;; If yes, complete the following:
+214 ;;
+215 ;; b. Is the neoplasm
+216 ;; ___ Benign ___ Malignant
+217 ;;
+218 ;; c. Has the Veteran completed treatment or is the Veteran currently
+219 ;; undergoing treatment for a benign or malignant neoplasm or metastases?
+220 ;; ___ Yes ___ No; watchful waiting
+221 ;; If yes, indicate type of treatment the Veteran is currently undergoing or
+222 ;; has completed (check all that apply):
+223 ;; ___ Treatment completed; currently in watchful waiting status
+224 ;; ___ Surgery
+225 ;; If checked, describe: ____________________
+226 ;; Date(s) of surgery: ______________________
+227 ;; ___ Radiation therapy
+228 ;; Date of most recent treatment: ___________
+229 ;; Date of completion of treatment or anticipated date of completion: _____
+230 ;; ___ Antineoplastic chemotherapy
+231 ;; Date of most recent treatment: ___________
+232 ;; Date of completion of treatment or anticipated date of completion: _____
+233 ;; ___ Other therapeutic procedure
+234 ;; If checked, describe procedure: ________________________________________
+235 ;; Date of most recent procedure: ___________
+236 ;; ___ Other therapeutic treatment
+237 ;; If checked, describe treatment: ________________________________________
+238 ;; Date of completion of treatment or anticipated date of completion:
+239 ;; ___________________
+240 ;;^TOF^
+241 ;; d. Does the Veteran currently have any residual conditions or complications
+242 ;; due to the neoplasm (including metastases) or its treatment, other than
+243 ;; those already documented in the report above?
+244 ;; ___ Yes ___ No
+245 ;; If yes, list residual conditions and complications (brief summary): ________
+246 ;;
+247 ;; e. If there are additional benign or malignant neoplasms or metastases
+248 ;; related to any of the diagnoses in the Diagnosis section, describe using the
+249 ;; above format: ______________________________________________________________
+250 ;;
+251 ;; 8. Other pertinent physical findings, complications, conditions, signs
+252 ;; and/or symptoms
+253 ;;
+254 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+255 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+256 ;; section above?
+257 ;; ___ Yes ___ No
+258 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+259 ;; of all related scars greater than 39 square cm (6 square inches)?
+260 ;; ___ Yes ___ No
+261 ;; If yes, also complete a Scars Questionnaire.
+262 ;;
+263 ;; b. Does the Veteran have any other pertinent physical findings,
+264 ;; complications, conditions, signs and/or symptoms related to any conditions
+265 ;; in the Diagnosis section above?
+266 ;; ___ Yes ___ No
+267 ;; If yes, describe (brief summary): __________________________________________
+268 ;;
+269 ;; 9. Diagnostic testing
+270 ;;
+271 ;; NOTE: If testing has been performed and reflects Veteran's current
+272 ;; condition, no further testing is required for this examination report.
+273 ;;
+274 ;; a. Have diagnostic imaging studies or other diagnostic procedures been
+275 ;; performed?
+276 ;; ___ Yes ___ No
+277 ;; If yes, check all that apply:
+278 ;; ___ Magnetic resonance imaging (MRI)
+279 ;; Date: ___________ Results: _______________
+280 ;; ___ Computerized axial tomography (CT)
+281 ;; Date: ___________ Results: ______________
+282 ;; ___ Electronystagmography (ENG)
+283 ;; Date: ___________ Results: ______________
+284 ;; ___ Other, specify: __________________________
+285 ;; Date: ___________ Results: ______________
+286 ;;^TOF^
+287 ;; b. Has the Veteran had an audiogram?
+288 ;; ___ Yes ___ No
+289 ;; If yes, attach or provide results: _________________________________________
+290 ;; If the Veteran has hearing loss or tinnitus, a Hearing and Tinnitus exam
+291 ;; must ALSO be scheduled.
+292 ;;
+293 ;; c. Are there any other significant diagnostic test findings and/or results?
+294 ;; ___ Yes ___ No
+295 ;; If yes, provide type of test or procedure, date and results (brief summary):
+296 ;; ____________________________________________________________________________
+297 ;;
+298 ;; 10. Functional impact
+299 ;;
+300 ;; Do any of the Veteran's ear or peripheral vestibular conditions impact his
+301 ;; or her ability to work?
+302 ;; ___ Yes ___ No
+303 ;; If yes, describe impact of each of the Veteran's ear or peripheral
+304 ;; vestibular conditions, providing one or more examples: _____________________
+305 ;;
+306 ;;_____________________________________________________________________________
+307 ;;
+308 ;; 11. Remarks, if any:________________________________________________________
+309 ;;
+310 ;; Physician signature: ____________________________________ Date: ____________
+311 ;;
+312 ;; Physician printed name: _________________________________ Phone: ___________
+313 ;;
+314 ;; Medical license #: ______________________________________ FAX: _____________
+315 ;;
+316 ;; Physician address: _________________________________________________________
+317 ;;
+318 ;; NOTE: VA may request additional medical information, including additional
+319 ;; examinations if necessary to complete VA's review of the Veteran's
+320 ;; application.
+321 ;;^END^
+322 QUIT
