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Routine: DVBCQES2

DVBCQES2.m

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  1. DVBCQES2 ;;ALB-CIOFO/ECF - ESOPHAGEAL DISORDERS QUESTIONNAIRE ; 6/10/2011
  1.  ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
  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.  ;; NOTE: The diagnosis of gastroesophageal reflux disease (GERD) can be made
  1.  ;; clinically by evidence of relief of typical symptoms of reflux, epigastric
  1.  ;; discomfort and/or burning, by treatment with proton pump inhibitors,
  1.  ;; histamine 2 receptor antagonists  and/or antacids. If upper endoscopy was
  1.  ;; indicated or performed, the findings of erythema, ulcers and/or strictures
  1.  ;; are consistent with the diagnosis of GERD.
  1.  ;;
  1.  ;; 1. Diagnosis:
  1.  ;;
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with an
  1.  ;; esophageal condition? 
  1.  ;; ___ Yes  ___ No
  1.  ;;
  1.  ;; If yes, indicate diagnoses: (check all that apply)
  1.  ;;
  1.  ;; ___ GERD                      ICD code: _______   Date of diagnosis: _______
  1.  ;; ___ Hiatal hernia             ICD code: _______   Date of diagnosis: _______
  1.  ;; ___ Esophageal stricture      ICD code: _______   Date of diagnosis: _______
  1.  ;; ___ Esophageal spasm          ICD code: _______   Date of diagnosis: _______
  1.  ;; ___ Esophageal diverticulum   ICD code: _______   Date of diagnosis: _______
  1.  ;; ___ Other esophageal condition (such as eosinophilic esophagitis, Barrett's
  1.  ;;     esophagus, etc.)
  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 esophageal disorders,
  1.  ;; list using above format:  __________________________________________________
  1.  ;;^TOF^
  1.  ;; 2. Medical history
  1.  ;;
  1.  ;; a.  Describe the history (including onset and course) of the Veteran's
  1.  ;; esophageal 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. Signs and symptoms
  1.  ;;
  1.  ;; Does the Veteran have any of the following signs or symptoms due to any
  1.  ;; esophageal conditions (including GERD)?
  1.  ;; ___ Yes   ___No
  1.  ;; If yes, check all that apply:
  1.  ;; ___ Persistently recurrent epigastric distress
  1.  ;; ___ Infrequent episodes of epigastric distress
  1.  ;; ___ Dysphagia
  1.  ;; ___ Pyrosis (heartburn)
  1.  ;; ___ Reflux
  1.  ;; ___ Regurgitation
  1.  ;; ___ Substernal arm or shoulder pain
  1.  ;; ___ Sleep disturbance caused by esophageal reflux
  1.  ;;     If checked, indicate frequency of symptom recurrence per year:
  1.  ;;     ___ 1   ___ 2    ___ 3   ___ 4 or more
  1.  ;;     If checked, indicate average duration of episodes of symptoms:
  1.  ;;     ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more
  1.  ;; ___ Anemia
  1.  ;;     If checked, provide hemoglobin/hematocrit in diagnostic testing section.
  1.  ;; ___ Weight loss
  1.  ;;     If checked, provide baseline weight: _______ and current weight: ________
  1.  ;;     (For VA purposes, baseline weight is the average weight for 2-year period
  1.  ;;     preceding onset of disease)
  1.  ;; ___ Nausea
  1.  ;;     If checked, indicate severity:
  1.  ;;     ___  Mild    ___ Transient   ___ Recurrent  ___ Periodic
  1.  ;;     If checked, indicate frequency of episodes of nausea per year:
  1.  ;;     ___ 1   ___ 2    ___ 3   ___ 4 or more
  1.  ;;     If checked, indicate average duration of episodes of vomiting:
  1.  ;;     ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more
  1.  ;; ___ Vomiting
  1.  ;;     If checked, indicate severity:
  1.  ;;     ___  Mild    ___ Transient   ___ Recurrent  ___ Periodic
  1.  ;;     If checked, indicate frequency of episodes of vomiting per year:
  1.  ;;     ___ 1   ___ 2    ___ 3   ___ 4 or more
  1.  ;;     If checked, indicate average duration of episodes of vomiting:
  1.  ;;     ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more
  1.  ;;^TOF^
  1.  ;; ___ Hematemesis
  1.  ;;     If checked, indicate severity:
  1.  ;;     ___ Mild    ___ Transient   ___ Recurrent  ___ Periodic
  1.  ;;     If checked, indicate frequency of episodes of hematemesis per year:
  1.  ;;     ___ 1   ___ 2    ___ 3   ___ 4 or more
  1.  ;;     If checked, indicate average duration of episodes of hematemesis:
  1.  ;;     ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more
  1.  ;; ___ Melena
  1.  ;;     If checked, indicate severity:
  1.  ;;     ___ Mild    ___ Transient   ___ Recurrent  ___ Periodic
  1.  ;;     If checked, indicate frequency of episodes of melena per year:
  1.  ;;     ___ 1   ___ 2    ___ 3   ___ 4 or more
  1.  ;;     If checked, indicate average duration of episodes of melena:
  1.  ;;     ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more
  1.  ;;
  1.  ;; 4. Esophageal stricture, spasm and diverticula
  1.  ;;
  1.  ;; Does the Veteran have an esophageal stricture, spasm of esophagus
  1.  ;; (cardiospasm or achalasia), or an acquired diverticulum of the esophagus?  
  1.  ;; ___ Yes   ___No
  1.  ;; If yes, indicate severity of condition:
  1.  ;; ___ Asymptomatic
  1.  ;; ___ Not amenable to dilation
  1.  ;; ___ Mild
  1.  ;;     If checked, describe: __________________________________________________
  1.  ;; ___ Moderate
  1.  ;;     If checked, describe: __________________________________________________
  1.  ;; ___ Severe, permitting passage of liquids only
  1.  ;;     If checked, describe: __________________________________________________
  1.  ;;
  1.  ;; 5. 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.  ;;^TOF^
  1.  ;; 6.  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.  ;;    ___ Upper endoscopy
  1.  ;;        Date: ___________ Results: __________________________________________
  1.  ;;    ___ Upper GI radiographic studies
  1.  ;;        Date: ___________ Results: __________________________________________
  1.  ;;    ___ Esophagram (barium swallow)
  1.  ;;        Date: ___________ Results: __________________________________________
  1.  ;;    ___ MRI
  1.  ;;        Date: ___________ Results: __________________________________________
  1.  ;;    ___ CT
  1.  ;;        Date: ___________ Results: __________________________________________
  1.  ;;    ___ Biopsy, specify site: _______________________________________________
  1.  ;;        Date: ___________ Results: __________________________________________
  1.  ;;    ___ Other, specify: _____________________________________________________
  1.  ;;        Date: ___________ Results: __________________________________________
  1.  ;;
  1.  ;; b. Has laboratory testing been performed?
  1.  ;; ___ Yes   ___No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ CBC        Date of test: ___________
  1.  ;;        Hemoglobin: ______              Hematocrit: _________
  1.  ;;        White blood cell count: ______  Platelets: __________
  1.  ;;    ___ Helicobacter pylori
  1.  ;;        Date of test: ___________  Results: _________________________________
  1.  ;;    ___ Other, specify: _____________________________________________________
  1.  ;;        Date of test: ___________  Results: _________________________________
  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.  ;; 7. Functional impact
  1.  ;;
  1.  ;; Do any of the Veteran's esophageal conditions impact on his or her ability
  1.  ;; to work?
  1.  ;; ___ Yes   ___No
  1.  ;; If yes, describe impact of each of the Veteran's esophageal conditions,
  1.  ;; providing one or more examples: ____________________________________________
  1.  ;;^TOF^
  1.  ;; 8. Remarks, if any:  _______________________________________________________
  1.  ;;
  1.  ;; ____________________________________________________________________________
  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