DVBCQES2 ;;ALB-CIOFO/ECF - ESOPHAGEAL DISORDERS QUESTIONNAIRE ; 6/10/2011
;;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.
;;
;; NOTE: The diagnosis of gastroesophageal reflux disease (GERD) can be made
;; clinically by evidence of relief of typical symptoms of reflux, epigastric
;; discomfort and/or burning, by treatment with proton pump inhibitors,
;; histamine 2 receptor antagonists and/or antacids. If upper endoscopy was
;; indicated or performed, the findings of erythema, ulcers and/or strictures
;; are consistent with the diagnosis of GERD.
;;
;; 1. Diagnosis:
;;
;; Does the Veteran now have or has he/she ever been diagnosed with an
;; esophageal condition?
;; ___ Yes ___ No
;;
;; If yes, indicate diagnoses: (check all that apply)
;;
;; ___ GERD ICD code: _______ Date of diagnosis: _______
;; ___ Hiatal hernia ICD code: _______ Date of diagnosis: _______
;; ___ Esophageal stricture ICD code: _______ Date of diagnosis: _______
;; ___ Esophageal spasm ICD code: _______ Date of diagnosis: _______
;; ___ Esophageal diverticulum ICD code: _______ Date of diagnosis: _______
;; ___ Other esophageal condition (such as eosinophilic esophagitis, Barrett's
;; esophagus, etc.)
;;
;; Other diagnosis #1: __________________
;; ICD code: ___________________________
;; Date of diagnosis: ___________________
;;
;; Other diagnosis #2: __________________
;; ICD code: ___________________________
;; Date of diagnosis: ___________________
;;
;; If there are additional diagnoses that pertain to esophageal disorders,
;; list using above format: __________________________________________________
;;^TOF^
;; 2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's
;; esophageal 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. Signs and symptoms
;;
;; Does the Veteran have any of the following signs or symptoms due to any
;; esophageal conditions (including GERD)?
;; ___ Yes ___No
;; If yes, check all that apply:
;; ___ Persistently recurrent epigastric distress
;; ___ Infrequent episodes of epigastric distress
;; ___ Dysphagia
;; ___ Pyrosis (heartburn)
;; ___ Reflux
;; ___ Regurgitation
;; ___ Substernal arm or shoulder pain
;; ___ Sleep disturbance caused by esophageal reflux
;; If checked, indicate frequency of symptom recurrence per year:
;; ___ 1 ___ 2 ___ 3 ___ 4 or more
;; If checked, indicate average duration of episodes of symptoms:
;; ___ Less than 1 day ___ 1-9 days ___ 10 days or more
;; ___ Anemia
;; If checked, provide hemoglobin/hematocrit in diagnostic testing section.
;; ___ Weight loss
;; If checked, provide baseline weight: _______ and current weight: ________
;; (For VA purposes, baseline weight is the average weight for 2-year period
;; preceding onset of disease)
;; ___ Nausea
;; If checked, indicate severity:
;; ___ Mild ___ Transient ___ Recurrent ___ Periodic
;; If checked, indicate frequency of episodes of nausea per year:
;; ___ 1 ___ 2 ___ 3 ___ 4 or more
;; If checked, indicate average duration of episodes of vomiting:
;; ___ Less than 1 day ___ 1-9 days ___ 10 days or more
;; ___ Vomiting
;; If checked, indicate severity:
;; ___ Mild ___ Transient ___ Recurrent ___ Periodic
;; If checked, indicate frequency of episodes of vomiting per year:
;; ___ 1 ___ 2 ___ 3 ___ 4 or more
;; If checked, indicate average duration of episodes of vomiting:
;; ___ Less than 1 day ___ 1-9 days ___ 10 days or more
;;^TOF^
;; ___ Hematemesis
;; If checked, indicate severity:
;; ___ Mild ___ Transient ___ Recurrent ___ Periodic
;; If checked, indicate frequency of episodes of hematemesis per year:
;; ___ 1 ___ 2 ___ 3 ___ 4 or more
;; If checked, indicate average duration of episodes of hematemesis:
;; ___ Less than 1 day ___ 1-9 days ___ 10 days or more
;; ___ Melena
;; If checked, indicate severity:
;; ___ Mild ___ Transient ___ Recurrent ___ Periodic
;; If checked, indicate frequency of episodes of melena per year:
;; ___ 1 ___ 2 ___ 3 ___ 4 or more
;; If checked, indicate average duration of episodes of melena:
;; ___ Less than 1 day ___ 1-9 days ___ 10 days or more
;;
;; 4. Esophageal stricture, spasm and diverticula
;;
;; Does the Veteran have an esophageal stricture, spasm of esophagus
;; (cardiospasm or achalasia), or an acquired diverticulum of the esophagus?
;; ___ Yes ___No
;; If yes, indicate severity of condition:
;; ___ Asymptomatic
;; ___ Not amenable to dilation
;; ___ Mild
;; If checked, describe: __________________________________________________
;; ___ Moderate
;; If checked, describe: __________________________________________________
;; ___ Severe, permitting passage of liquids only
;; If checked, describe: __________________________________________________
;;
;; 5. 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): __________________________________________
;;^TOF^
;; 6. 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:
;; ___ Upper endoscopy
;; Date: ___________ Results: __________________________________________
;; ___ Upper GI radiographic studies
;; Date: ___________ Results: __________________________________________
;; ___ Esophagram (barium swallow)
;; Date: ___________ Results: __________________________________________
;; ___ MRI
;; Date: ___________ Results: __________________________________________
;; ___ CT
;; Date: ___________ Results: __________________________________________
;; ___ Biopsy, specify site: _______________________________________________
;; Date: ___________ Results: __________________________________________
;; ___ Other, specify: _____________________________________________________
;; Date: ___________ Results: __________________________________________
;;
;; b. Has laboratory testing been performed?
;; ___ Yes ___No
;; If yes, check all that apply:
;; ___ CBC Date of test: ___________
;; Hemoglobin: ______ Hematocrit: _________
;; White blood cell count: ______ Platelets: __________
;; ___ Helicobacter pylori
;; Date of test: ___________ Results: _________________________________
;; ___ Other, specify: _____________________________________________________
;; Date of test: ___________ Results: _________________________________
;;
;; 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):
;; ____________________________________________________________________________
;;
;; 7. Functional impact
;;
;; Do any of the Veteran's esophageal conditions impact on his or her ability
;; to work?
;; ___ Yes ___No
;; If yes, describe impact of each of the Veteran's esophageal conditions,
;; providing one or more examples: ____________________________________________
;;^TOF^
;; 8. 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[HDVBCQES2 9737 printed Apr 09, 2024@20:50:06 Page 2
DVBCQES2 ;;ALB-CIOFO/ECF - ESOPHAGEAL DISORDERS QUESTIONNAIRE ; 6/10/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+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 ;; NOTE: The diagnosis of gastroesophageal reflux disease (GERD) can be made
+8 ;; clinically by evidence of relief of typical symptoms of reflux, epigastric
+9 ;; discomfort and/or burning, by treatment with proton pump inhibitors,
+10 ;; histamine 2 receptor antagonists and/or antacids. If upper endoscopy was
+11 ;; indicated or performed, the findings of erythema, ulcers and/or strictures
+12 ;; are consistent with the diagnosis of GERD.
+13 ;;
+14 ;; 1. Diagnosis:
+15 ;;
+16 ;; Does the Veteran now have or has he/she ever been diagnosed with an
+17 ;; esophageal condition?
+18 ;; ___ Yes ___ No
+19 ;;
+20 ;; If yes, indicate diagnoses: (check all that apply)
+21 ;;
+22 ;; ___ GERD ICD code: _______ Date of diagnosis: _______
+23 ;; ___ Hiatal hernia ICD code: _______ Date of diagnosis: _______
+24 ;; ___ Esophageal stricture ICD code: _______ Date of diagnosis: _______
+25 ;; ___ Esophageal spasm ICD code: _______ Date of diagnosis: _______
+26 ;; ___ Esophageal diverticulum ICD code: _______ Date of diagnosis: _______
+27 ;; ___ Other esophageal condition (such as eosinophilic esophagitis, Barrett's
+28 ;; esophagus, etc.)
+29 ;;
+30 ;; Other diagnosis #1: __________________
+31 ;; ICD code: ___________________________
+32 ;; Date of diagnosis: ___________________
+33 ;;
+34 ;; Other diagnosis #2: __________________
+35 ;; ICD code: ___________________________
+36 ;; Date of diagnosis: ___________________
+37 ;;
+38 ;; If there are additional diagnoses that pertain to esophageal disorders,
+39 ;; list using above format: __________________________________________________
+40 ;;^TOF^
+41 ;; 2. Medical history
+42 ;;
+43 ;; a. Describe the history (including onset and course) of the Veteran's
+44 ;; esophageal conditions (brief summary): _____________________________________
+45 ;;
+46 ;; b. Does the Veteran's treatment plan include taking continuous medication
+47 ;; for the diagnosed condition?
+48 ;; ___ Yes ___No
+49 ;; If yes, list only those medications used for the diagnosed condition:
+50 ;; ____________________________________________________________________________
+51 ;;
+52 ;; 3. Signs and symptoms
+53 ;;
+54 ;; Does the Veteran have any of the following signs or symptoms due to any
+55 ;; esophageal conditions (including GERD)?
+56 ;; ___ Yes ___No
+57 ;; If yes, check all that apply:
+58 ;; ___ Persistently recurrent epigastric distress
+59 ;; ___ Infrequent episodes of epigastric distress
+60 ;; ___ Dysphagia
+61 ;; ___ Pyrosis (heartburn)
+62 ;; ___ Reflux
+63 ;; ___ Regurgitation
+64 ;; ___ Substernal arm or shoulder pain
+65 ;; ___ Sleep disturbance caused by esophageal reflux
+66 ;; If checked, indicate frequency of symptom recurrence per year:
+67 ;; ___ 1 ___ 2 ___ 3 ___ 4 or more
+68 ;; If checked, indicate average duration of episodes of symptoms:
+69 ;; ___ Less than 1 day ___ 1-9 days ___ 10 days or more
+70 ;; ___ Anemia
+71 ;; If checked, provide hemoglobin/hematocrit in diagnostic testing section.
+72 ;; ___ Weight loss
+73 ;; If checked, provide baseline weight: _______ and current weight: ________
+74 ;; (For VA purposes, baseline weight is the average weight for 2-year period
+75 ;; preceding onset of disease)
+76 ;; ___ Nausea
+77 ;; If checked, indicate severity:
+78 ;; ___ Mild ___ Transient ___ Recurrent ___ Periodic
+79 ;; If checked, indicate frequency of episodes of nausea per year:
+80 ;; ___ 1 ___ 2 ___ 3 ___ 4 or more
+81 ;; If checked, indicate average duration of episodes of vomiting:
+82 ;; ___ Less than 1 day ___ 1-9 days ___ 10 days or more
+83 ;; ___ Vomiting
+84 ;; If checked, indicate severity:
+85 ;; ___ Mild ___ Transient ___ Recurrent ___ Periodic
+86 ;; If checked, indicate frequency of episodes of vomiting per year:
+87 ;; ___ 1 ___ 2 ___ 3 ___ 4 or more
+88 ;; If checked, indicate average duration of episodes of vomiting:
+89 ;; ___ Less than 1 day ___ 1-9 days ___ 10 days or more
+90 ;;^TOF^
+91 ;; ___ Hematemesis
+92 ;; If checked, indicate severity:
+93 ;; ___ Mild ___ Transient ___ Recurrent ___ Periodic
+94 ;; If checked, indicate frequency of episodes of hematemesis per year:
+95 ;; ___ 1 ___ 2 ___ 3 ___ 4 or more
+96 ;; If checked, indicate average duration of episodes of hematemesis:
+97 ;; ___ Less than 1 day ___ 1-9 days ___ 10 days or more
+98 ;; ___ Melena
+99 ;; If checked, indicate severity:
+100 ;; ___ Mild ___ Transient ___ Recurrent ___ Periodic
+101 ;; If checked, indicate frequency of episodes of melena per year:
+102 ;; ___ 1 ___ 2 ___ 3 ___ 4 or more
+103 ;; If checked, indicate average duration of episodes of melena:
+104 ;; ___ Less than 1 day ___ 1-9 days ___ 10 days or more
+105 ;;
+106 ;; 4. Esophageal stricture, spasm and diverticula
+107 ;;
+108 ;; Does the Veteran have an esophageal stricture, spasm of esophagus
+109 ;; (cardiospasm or achalasia), or an acquired diverticulum of the esophagus?
+110 ;; ___ Yes ___No
+111 ;; If yes, indicate severity of condition:
+112 ;; ___ Asymptomatic
+113 ;; ___ Not amenable to dilation
+114 ;; ___ Mild
+115 ;; If checked, describe: __________________________________________________
+116 ;; ___ Moderate
+117 ;; If checked, describe: __________________________________________________
+118 ;; ___ Severe, permitting passage of liquids only
+119 ;; If checked, describe: __________________________________________________
+120 ;;
+121 ;; 5. Other pertinent physical findings, complications, conditions, signs
+122 ;; and/or symptoms
+123 ;;
+124 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+125 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+126 ;; section above?
+127 ;; ___ Yes ___No
+128 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+129 ;; of all related scars greater than 39 square cm (6 square inches)?
+130 ;; ___ Yes ___No
+131 ;; If yes, also complete a Scars Questionnaire.
+132 ;;
+133 ;; b. Does the Veteran have any other pertinent physical findings,
+134 ;; complications, conditions, signs and/or symptoms related to any conditions
+135 ;; listed in the Diagnosis section above?
+136 ;; ___ Yes ___No
+137 ;; If yes, describe (brief summary): __________________________________________
+138 ;;^TOF^
+139 ;; 6. Diagnostic Testing
+140 ;;
+141 ;; NOTE: If testing has been performed and reflects Veteran's current
+142 ;; condition, no further testing is required for this examination report.
+143 ;;
+144 ;; a. Have diagnostic imaging studies or other diagnostic procedures been
+145 ;; performed?
+146 ;; ___ Yes ___No
+147 ;; If yes, check all that apply:
+148 ;; ___ Upper endoscopy
+149 ;; Date: ___________ Results: __________________________________________
+150 ;; ___ Upper GI radiographic studies
+151 ;; Date: ___________ Results: __________________________________________
+152 ;; ___ Esophagram (barium swallow)
+153 ;; Date: ___________ Results: __________________________________________
+154 ;; ___ MRI
+155 ;; Date: ___________ Results: __________________________________________
+156 ;; ___ CT
+157 ;; Date: ___________ Results: __________________________________________
+158 ;; ___ Biopsy, specify site: _______________________________________________
+159 ;; Date: ___________ Results: __________________________________________
+160 ;; ___ Other, specify: _____________________________________________________
+161 ;; Date: ___________ Results: __________________________________________
+162 ;;
+163 ;; b. Has laboratory testing been performed?
+164 ;; ___ Yes ___No
+165 ;; If yes, check all that apply:
+166 ;; ___ CBC Date of test: ___________
+167 ;; Hemoglobin: ______ Hematocrit: _________
+168 ;; White blood cell count: ______ Platelets: __________
+169 ;; ___ Helicobacter pylori
+170 ;; Date of test: ___________ Results: _________________________________
+171 ;; ___ Other, specify: _____________________________________________________
+172 ;; Date of test: ___________ Results: _________________________________
+173 ;;
+174 ;; c. Are there any other significant diagnostic test findings and/or results?
+175 ;; ___ Yes ___No
+176 ;; If yes, provide type of test or procedure, date and results (brief summary):
+177 ;; ____________________________________________________________________________
+178 ;;
+179 ;; 7. Functional impact
+180 ;;
+181 ;; Do any of the Veteran's esophageal conditions impact on his or her ability
+182 ;; to work?
+183 ;; ___ Yes ___No
+184 ;; If yes, describe impact of each of the Veteran's esophageal conditions,
+185 ;; providing one or more examples: ____________________________________________
+186 ;;^TOF^
+187 ;; 8. Remarks, if any: _______________________________________________________
+188 ;;
+189 ;; ____________________________________________________________________________
+190 ;;
+191 ;; Physician signature: _______________________________________ Date:__________
+192 ;;
+193 ;; Physician printed name: ____________________________________ Phone:_________
+194 ;;
+195 ;; Medical license #: _________________________________________ FAX: __________
+196 ;;
+197 ;; Physician address: _________________________________________________________
+198 ;;
+199 ;; NOTE: VA may request additional medical information, including additional
+200 ;; examinations if necessary to complete VA's review of the Veteran's
+201 ;; application.
+202 ;;^END^
+203 QUIT
