- 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 Dec 13, 2024@01:46:06 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