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Routine: DVBCQED2

DVBCQED2.m

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  1. 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
  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. ;;
  1. ;; Does the Veteran now have or has he/she ever been diagnosed with an ear or
  1. ;; peripheral vestibular condition?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, select the Veteran's condition (check all that apply):
  1. ;; ___ Meniere's syndrome or ICD code: ______ Date of diagnosis: _________
  1. ;; endolymphatic hydrops
  1. ;; ___ Peripheral vestibular ICD code: ______ Date of diagnosis: _________
  1. ;; disorder
  1. ;; ___ Benign Paroxysmal ICD code: ______ Date of diagnosis: _________
  1. ;; Positional Vertigo (BPPV)
  1. ;; ___ Chronic otitis externa ICD code: ______ Date of diagnosis: _________
  1. ;; ___ Chronic suppurative ICD code: ______ Date of diagnosis: _________
  1. ;; otitis media
  1. ;; ___ Chronic nonsuppurative ICD code: ______ Date of diagnosis: _________
  1. ;; otitis media (serous otitis media)
  1. ;; ___ Mastoiditis ICD code: ______ Date of diagnosis: _________
  1. ;; ___ Cholesteatoma ICD code: ______ Date of diagnosis: _________
  1. ;; If checked, a Hearing Loss and Tinnitus Questionnaire must ALSO
  1. ;; be completed.
  1. ;; ___ Otosclerosis ICD code: ______ Date of diagnosis: _________
  1. ;; If checked, a Hearing Loss and Tinnitus Questionnaire must be completed
  1. ;; in lieu of this Questionnaire.
  1. ;; ___ Benign neoplasm of the ICD code: ______ Date of diagnosis: _________
  1. ;; ear (other than skin only)
  1. ;; ___ Malignant neoplasm of ICD code: ______ Date of diagnosis: _________
  1. ;; the ear (other than skin only)
  1. ;; ___ Other, specify:
  1. ;;
  1. ;; Other diagnosis #1: ______________
  1. ;; ICD code: ________________________
  1. ;; Date of diagnosis: _______________
  1. ;;
  1. ;; Other diagnosis #2: ______________
  1. ;; ICD code: ________________________
  1. ;; Date of diagnosis: _______________
  1. ;;
  1. ;; If there are additional diagnoses that pertain to ear or peripheral
  1. ;; vestibular conditions, list using above format: ____________________________
  1. ;;
  1. ;; NOTE: If the Veteran has hearing loss or tinnitus attributable to any ear
  1. ;; condition listed above, a Hearing Loss and Tinnitus Questionnaire must ALSO
  1. ;; be completed.
  1. ;;^TOF^
  1. ;; 2. Medical history
  1. ;;
  1. ;; a. Describe the history (including onset and course) of the Veteran's ear
  1. ;; or peripheral vestibular conditions (brief summary): _______________________
  1. ;;
  1. ;; b. Does the Veteran's treatment plan include taking continuous medication
  1. ;; for the diagnosed condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, list only those medications used for the diagnosed condition:
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; 3. Vestibular conditions
  1. ;;
  1. ;; Does the Veteran have any of the following findings, signs or symptoms
  1. ;; attributable to Meniere's syndrome (endolymphatic hydrops), a peripheral
  1. ;; vestibular condition or another diagnosed condition from Section 1?
  1. ;; ___ Yes ___ No
  1. ;; If yes, check all that apply:
  1. ;; ___ Hearing impairment with vertigo
  1. ;; If checked, indicate frequency:
  1. ;; ___ Less than once a month
  1. ;; ___ 1 to 4 times per month
  1. ;; ___ More than once weekly
  1. ;; Indicate duration of episodes:
  1. ;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
  1. ;; ___ Hearing impairment with attacks of vertigo and cerebellar gait
  1. ;; If checked, indicate frequency:
  1. ;; ___ Less than once a month
  1. ;; ___ 1 to 4 times per month
  1. ;; ___ More than once weekly
  1. ;; Indicate duration of episodes:
  1. ;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
  1. ;; ___ Tinnitus, unilateral or bilateral
  1. ;; If checked, indicate frequency:
  1. ;; ___ Less than once a month
  1. ;; ___ 1 to 4 times per month
  1. ;; ___ More than once weekly
  1. ;; Indicate duration of episodes:
  1. ;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
  1. ;; ___ Vertigo
  1. ;; If checked, indicate frequency:
  1. ;; ___ Less than once a month
  1. ;; ___ 1 to 4 times per month
  1. ;; ___ More than once weekly
  1. ;; Indicate duration of episodes:
  1. ;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
  1. ;;^TOF^
  1. ;; ___ Staggering
  1. ;; If checked, indicate frequency:
  1. ;; ___ Less than once a month
  1. ;; ___ 1 to 4 times per month
  1. ;; ___ More than once weekly
  1. ;; Indicate duration of episodes:
  1. ;; ___ <1 hour ___ 1 to 24 hours ___ >24 hours
  1. ;; ___ Hearing impairment and/or tinnitus
  1. ;; If checked, a Hearing Loss and Tinnitus Questionnaire must ALSO be
  1. ;; completed.
  1. ;; ___ Other, describe: _______________________________________________________
  1. ;;
  1. ;; 4. Infectious, inflammatory and other ear conditions
  1. ;;
  1. ;; a. Does the Veteran have any of the following findings, signs or symptoms
  1. ;; attributable to chronic ear infection, inflammation, cholesteatoma or any
  1. ;; of the diagnoses in Section 1?
  1. ;; ___ Yes ___ No
  1. ;; If yes, check all that apply:
  1. ;; ___ Swelling (external ear canal)
  1. ;; If checked, describe: _______________________________________________
  1. ;; ___ Dry and scaly (external ear canal)
  1. ;; ___ Serous discharge (external ear canal)
  1. ;; ___ Itching (external ear canal)
  1. ;; ___ Effusion
  1. ;; ___ Active suppuration
  1. ;; ___ Aural polyps
  1. ;; ___ Hearing impairment and/or tinnitus
  1. ;; If checked, a Hearing Loss and Tinnitus Questionnaire must ALSO be
  1. ;; completed.
  1. ;; ___ Facial nerve paralysis
  1. ;; If checked, ALSO complete Cranial Nerves Questionnaire.
  1. ;; ___ Bone loss of skull
  1. ;; If checked, indicate severity:
  1. ;; ___ Area lost smaller than an American quarter (4.619 cm2)
  1. ;; ___ Area lost larger than an American quarter but smaller than a
  1. ;; 50-cent piece
  1. ;; ___ Area lost larger than an American 50-cent piece (7.355 cm2)
  1. ;; ___ Requiring frequent and prolonged treatment
  1. ;; If checked, describe type and durations of treatment: __________________
  1. ;; ___ Other, describe: _______________________________________________________
  1. ;;
  1. ;; b. Does the Veteran have a benign neoplasm of the ear (other than skin only,
  1. ;; such as keloid) that causes any impairment of function?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe impairment of function caused by this condition: __________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;^TOF^
  1. ;; 5. Surgical treatment
  1. ;;
  1. ;; a. Has the Veteran had surgical treatment for any ear condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, indicate type of surgery: __________________________________________
  1. ;; Date: ______________
  1. ;; Side affected: ___ Right ___ Left ___ Both
  1. ;;
  1. ;; b. Does the Veteran have any residuals as a result of the surgery?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe: __________________________________________________________
  1. ;;
  1. ;; 6. Physical exam
  1. ;;
  1. ;; a. External ear
  1. ;; ___ Exam of external ear not indicated
  1. ;; ___ Normal
  1. ;; ___ Deformity of auricle, with loss of less than one-third of the
  1. ;; substance
  1. ;; If checked, specify side: ___ Right ___ Left
  1. ;; ___ Deformity of auricle, with loss of one-third or more of the substance
  1. ;; If checked, specify side: ___ Right ___ Left
  1. ;; ___ Complete loss of auricle
  1. ;; If checked, specify side: ___ Right ___ Left
  1. ;; ___ Other abnormality, describe: __________________________________________
  1. ;;
  1. ;; b. Ear canal:
  1. ;; ___ Exam of ear canal not indicated
  1. ;; ___ Normal
  1. ;; ___ Abnormal, describe: ____________________________________________________
  1. ;;
  1. ;; c. Tympanic membrane:
  1. ;; ___ Exam of tympanic membrane not indicated
  1. ;; ___ Normal
  1. ;; ___ Perforated tympanic membrane
  1. ;; If checked, specify side affected: ___ Right ___ Left
  1. ;; ___ Evidence of a healed tympanic membrane perforation
  1. ;; If checked, specify side affected: ___ Right ___ Left
  1. ;; ___ Other abnormality, describe: ___________________________________________
  1. ;;
  1. ;; d. Gait:
  1. ;; ___ Exam of gait not indicated
  1. ;; ___ Normal
  1. ;; ___ Unsteady, describe: ____________________________________________________
  1. ;; ___ Other abnormality, describe: ___________________________________________
  1. ;;^TOF^
  1. ;; e. Romberg test:
  1. ;; ___ Exam using this test not indicated
  1. ;; ___ Normal or negative
  1. ;; ___ Abnormal or positive for unsteadiness
  1. ;;
  1. ;; f. Dix Hallpike test (Nylen-Barany test) for vertigo
  1. ;; ___ Exam using this test not indicated
  1. ;; ___ Normal, no vertigo or nystagmus during test
  1. ;; ___ Abnormal, vertigo or nystagmus during test, describe: __________________
  1. ;;
  1. ;; g. Limb coordination test (finger-nose-finger)
  1. ;; ___ Exam using this test not indicated
  1. ;; ___ Normal
  1. ;; ___ Abnormal, describe: ____________________________________________________
  1. ;;
  1. ;; 7. Tumors and neoplasms
  1. ;;
  1. ;; a. Does the Veteran have a benign or malignant neoplasm or metastases
  1. ;; related to any of the diagnoses in the Diagnosis section?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following:
  1. ;;
  1. ;; b. Is the neoplasm
  1. ;; ___ Benign ___ Malignant
  1. ;;
  1. ;; c. Has the Veteran completed treatment or is the Veteran currently
  1. ;; undergoing treatment for a benign or malignant neoplasm or metastases?
  1. ;; ___ Yes ___ No; watchful waiting
  1. ;; If yes, indicate type of treatment the Veteran is currently undergoing or
  1. ;; has completed (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. ;; ___ Antineoplastic chemotherapy
  1. ;; Date of most recent treatment: ___________
  1. ;; Date of completion of treatment or anticipated date of completion: _____
  1. ;; ___ Other therapeutic procedure
  1. ;; If checked, describe procedure: ________________________________________
  1. ;; Date of most recent procedure: ___________
  1. ;; ___ Other therapeutic treatment
  1. ;; If checked, describe treatment: ________________________________________
  1. ;; Date of completion of treatment or anticipated date of completion:
  1. ;; ___________________
  1. ;;^TOF^
  1. ;; d. Does the Veteran currently have any residual conditions or complications
  1. ;; due to the neoplasm (including metastases) or its treatment, other than
  1. ;; those already documented in the report above?
  1. ;; ___ Yes ___ No
  1. ;; If yes, list residual conditions and complications (brief summary): ________
  1. ;;
  1. ;; e. If there are additional benign or malignant neoplasms or metastases
  1. ;; related to any of the diagnoses in the Diagnosis section, describe using the
  1. ;; above format: ______________________________________________________________
  1. ;;
  1. ;; 8. 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. ;; in the Diagnosis section above?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe (brief summary): __________________________________________
  1. ;;
  1. ;; 9. Diagnostic testing
  1. ;;
  1. ;; NOTE: If testing has been performed and reflects Veteran's current
  1. ;; condition, no further testing is required for this examination report.
  1. ;;
  1. ;; a. Have diagnostic imaging studies or other diagnostic procedures been
  1. ;; performed?
  1. ;; ___ Yes ___ No
  1. ;; If yes, check all that apply:
  1. ;; ___ Magnetic resonance imaging (MRI)
  1. ;; Date: ___________ Results: _______________
  1. ;; ___ Computerized axial tomography (CT)
  1. ;; Date: ___________ Results: ______________
  1. ;; ___ Electronystagmography (ENG)
  1. ;; Date: ___________ Results: ______________
  1. ;; ___ Other, specify: __________________________
  1. ;; Date: ___________ Results: ______________
  1. ;;^TOF^
  1. ;; b. Has the Veteran had an audiogram?
  1. ;; ___ Yes ___ No
  1. ;; If yes, attach or provide results: _________________________________________
  1. ;; If the Veteran has hearing loss or tinnitus, a Hearing and Tinnitus exam
  1. ;; must ALSO be scheduled.
  1. ;;
  1. ;; c. Are there any other significant diagnostic test findings and/or results?
  1. ;; ___ Yes ___ No
  1. ;; If yes, provide type of test or procedure, date and results (brief summary):
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; 10. Functional impact
  1. ;;
  1. ;; Do any of the Veteran's ear or peripheral vestibular conditions impact his
  1. ;; or her ability to work?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe impact of each of the Veteran's ear or peripheral
  1. ;; vestibular conditions, providing one or more examples: _____________________
  1. ;;
  1. ;;_____________________________________________________________________________
  1. ;;
  1. ;; 11. 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. ;;^END^
  1. Q