DVBCQEY2 ;;ALB-CIOFO/ECF - EYE CONDITIONS QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
;
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. This report is not for treatment purposes; it is to provide a
;; summary of medical information for disability claims resolution.
;;
;; NOTE: This examination must be conducted by a licensed ophthalmologist or
;; by a licensed optometrist. The examiner must identify the disease, injury
;; or other pathologic process responsible for any decrease in visual acuity
;; or other visual impairment found.
;;
;; Examinations of visual fields or muscle function should be conducted ONLY
;; when there is a medical indication of disease or injury that may be
;; associated with visual field defect or impaired muscle function.
;;
;; Unless medically contraindicated, the fundus must be examined with the
;; Veteran's pupils dilated.
;;
;; SECTION I: DIAGNOSES
;;
;; NOTE: The diagnosis section should be filled out AFTER the clinician has
;; completed the examination
;;
;; Does the Veteran now have or has he/she ever been diagnosed with an eye
;; condition (other than congenital or developmental errors of refraction)?
;; ___ Yes ___ No
;; If yes, provide only diagnoses that pertain to eye conditions:
;;
;; Diagnosis #1: ___________________
;; ICD code(s): ___________________
;; Date of diagnosis: ______________
;;
;; Diagnosis #2: ___________________
;; ICD code(s): ___________________
;; Date of diagnosis: ______________
;;
;; Diagnosis #3: ___________________
;; ICD code(s): ___________________
;; Date of diagnosis: ______________
;;
;; If there are additional diagnoses that pertain to eye conditions, list using
;; above format: ______________________________________________________________
;;^TOF^
;; SECTION II: MEDICAL HISTORY
;;
;; Describe the history (including onset and course) of the Veteran's current
;; eye condition(s) (brief summary):
;;
;; ____________________________________________________________________________
;;
;; SECTION III: PHYSICAL EXAMINATION
;;
;; 1. Visual acuity
;;
;; Visual acuity should be reported according to the lines on the Snellen chart
;; or its equivalent. If assessment of the Veteran's visual acuity falls
;; between two lines on the Snellen chart, round up to the higher (worse) level
;; (poorer vision) for answers a-d below. (For example, 20/60 would be reported
;; as 20/70; 20/80 would be reported as 20/100, etc.)
;;
;; Examination of visual acuity must include central uncorrected and corrected
;; visual acuity for distance and near vision. Evaluate central visual acuity
;; on the basis of corrected distance vision with central fixation. Visual
;; acuity should not be determined with eccentric fixation or viewing.
;;
;; a. Uncorrected distance:
;; Right: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
;; __20/50 __20/40 or better
;; Left: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
;; __20/50 __20/40 or better
;;
;; b. Uncorrected near:
;; Right: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
;; __20/50 __20/40 or better
;; Left: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
;; __20/50 __20/40 or better
;;
;; c. Corrected distance:
;; Right: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
;; __20/50 __20/40 or better
;; Left: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
;; __20/50 __20/40 or better
;;
;; d. Corrected near:
;; Right: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
;; __20/50 __20/40 or better
;; Left: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
;; __20/50 __20/40 or better
;;^TOF^
;; 2. Difference in corrected visual acuity for distance and near vision
;;
;; Does the Veteran have a difference equal to two or more lines on the Snellen
;; test type chart or its equivalent between distance and near corrected
;; vision, with the near vision being worse?
;; ___ Yes ___ No
;; If yes, complete the following section:
;;
;; a. Provide a second recording of corrected distance and near vision:
;; Second recording of corrected distance vision:
;; Right: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
;; __20/50 __20/40 or better
;; Left: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
;; __20/50 __20/40 or better
;;
;; Second recording of corrected near vision:
;; Right: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
;; __20/50 __20/40 or better
;; Left: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
;; __20/50 __20/40 or better
;;
;; b. Explain reason for the difference between distance and near corrected
;; vision: ____________________________________________________________________
;;
;; c. Does the lens required to correct distance vision in the poorer eye
;; differ by more than 3 diopters from the lens required to correct distance
;; vision in the better eye?
;; ___ Yes ___ No
;; If yes, explain reason for the difference: _________________________________
;;
;; 3. Pupils
;;
;; a. Pupil diameter: Right: _____mm Left: _____mm
;;
;; b. ___ Pupils are round and reactive to light
;;
;; c. Is an afferent pupillary defect present?
;;___ Yes ___ No
;; If yes, indicate eye: ___ Right ___ Left
;;
;; d. ___ Other, describe: ____________________________________________________
;; Eye affected: ___ Right ___ Left ___ Both
;;^TOF^
;; 4. Anatomical loss, light perception only, extremely poor vision or
;; blindness
;;
;; Does the Veteran have anatomical loss, light perception only, extremely
;; poor vision or blindness of either eye?
;; ___ Yes ___ No
;; If yes, complete the following section:
;;
;; a. Does the Veteran have anatomical loss of either eye?
;; ___ Yes ___ No
;; If yes, indicate eye:
;; ___ Right ___ Left ___ Both
;; If yes, is Veteran able to wear an ocular prosthesis?
;; ___ Yes ___ No
;; If no, provide reason: _____________________________________________________
;;
;; b. Is the Veteran's vision limited to no more than light perception only
;; in either eye?
;; ___ Yes ___ No
;; If yes, indicate for which eye(s) the Veteran's vision limited to no more
;; than light perception:
;; ___ Right ___ Left ___ Both
;;
;; c. Is the Veteran able to recognize test letters at 1 foot or closer?
;; ___ Yes ___ No
;; If no, indicate with which eye(s) the Veteran is unable to recognize test
;; letters at 1 foot or closer:
;; ___ Right ___ Left ___ Both
;;
;; d. Is the Veteran able to perceive objects, hand movements, or count fingers
;; at 3 feet?
;; ___ Yes ___ No
;; If no, indicate with which eye(s) the Veteran is unable to perceive objects,
;; hand movements, or count fingers at 3 feet:
;; ___ Right ___ Left ___ Both
;;
;; e. Does the Veteran have visual acuity of 20/200 or less in the better eye
;; with use of a correcting lens based upon visual acuity loss (i.e. USA
;; statutory blindness with bilateral visual acuity of 20/200 or less)?
;; ___ Yes ___ No
;;
;;^TOF^
;; 5. Astigmatism
;;
;; Does the Veteran have a corneal irregularity that results in severe
;; irregular astigmatism?
;; ___ Yes ___ No
;; If yes, complete the following section:
;;
;; a. Does the Veteran customarily wear contact lenses to correct the above
;; corneal irregularity?
;; ___ Yes ___ No
;; If yes, does using contact lenses result in more visual improvement than
;; using the standard spectacle correction?
;; ___ Yes ___ No
;;
;; b. Was the corrected visual acuity determined using contact lenses?
;; ___ Yes ___ No
;; If no, explain: ____________________________________________________________
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQEY2 8453 printed Dec 13, 2024@01:46:12 Page 2
DVBCQEY2 ;;ALB-CIOFO/ECF - EYE CONDITIONS QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA)
+3 ;; for disability benefits. VA will consider the information you provide on
+4 ;; this questionnaire as part of their evaluation in processing the Veteran's
+5 ;; claim. This report is not for treatment purposes; it is to provide a
+6 ;; summary of medical information for disability claims resolution.
+7 ;;
+8 ;; NOTE: This examination must be conducted by a licensed ophthalmologist or
+9 ;; by a licensed optometrist. The examiner must identify the disease, injury
+10 ;; or other pathologic process responsible for any decrease in visual acuity
+11 ;; or other visual impairment found.
+12 ;;
+13 ;; Examinations of visual fields or muscle function should be conducted ONLY
+14 ;; when there is a medical indication of disease or injury that may be
+15 ;; associated with visual field defect or impaired muscle function.
+16 ;;
+17 ;; Unless medically contraindicated, the fundus must be examined with the
+18 ;; Veteran's pupils dilated.
+19 ;;
+20 ;; SECTION I: DIAGNOSES
+21 ;;
+22 ;; NOTE: The diagnosis section should be filled out AFTER the clinician has
+23 ;; completed the examination
+24 ;;
+25 ;; Does the Veteran now have or has he/she ever been diagnosed with an eye
+26 ;; condition (other than congenital or developmental errors of refraction)?
+27 ;; ___ Yes ___ No
+28 ;; If yes, provide only diagnoses that pertain to eye conditions:
+29 ;;
+30 ;; Diagnosis #1: ___________________
+31 ;; ICD code(s): ___________________
+32 ;; Date of diagnosis: ______________
+33 ;;
+34 ;; Diagnosis #2: ___________________
+35 ;; ICD code(s): ___________________
+36 ;; Date of diagnosis: ______________
+37 ;;
+38 ;; Diagnosis #3: ___________________
+39 ;; ICD code(s): ___________________
+40 ;; Date of diagnosis: ______________
+41 ;;
+42 ;; If there are additional diagnoses that pertain to eye conditions, list using
+43 ;; above format: ______________________________________________________________
+44 ;;^TOF^
+45 ;; SECTION II: MEDICAL HISTORY
+46 ;;
+47 ;; Describe the history (including onset and course) of the Veteran's current
+48 ;; eye condition(s) (brief summary):
+49 ;;
+50 ;; ____________________________________________________________________________
+51 ;;
+52 ;; SECTION III: PHYSICAL EXAMINATION
+53 ;;
+54 ;; 1. Visual acuity
+55 ;;
+56 ;; Visual acuity should be reported according to the lines on the Snellen chart
+57 ;; or its equivalent. If assessment of the Veteran's visual acuity falls
+58 ;; between two lines on the Snellen chart, round up to the higher (worse) level
+59 ;; (poorer vision) for answers a-d below. (For example, 20/60 would be reported
+60 ;; as 20/70; 20/80 would be reported as 20/100, etc.)
+61 ;;
+62 ;; Examination of visual acuity must include central uncorrected and corrected
+63 ;; visual acuity for distance and near vision. Evaluate central visual acuity
+64 ;; on the basis of corrected distance vision with central fixation. Visual
+65 ;; acuity should not be determined with eccentric fixation or viewing.
+66 ;;
+67 ;; a. Uncorrected distance:
+68 ;; Right: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
+69 ;; __20/50 __20/40 or better
+70 ;; Left: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
+71 ;; __20/50 __20/40 or better
+72 ;;
+73 ;; b. Uncorrected near:
+74 ;; Right: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
+75 ;; __20/50 __20/40 or better
+76 ;; Left: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
+77 ;; __20/50 __20/40 or better
+78 ;;
+79 ;; c. Corrected distance:
+80 ;; Right: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
+81 ;; __20/50 __20/40 or better
+82 ;; Left: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
+83 ;; __20/50 __20/40 or better
+84 ;;
+85 ;; d. Corrected near:
+86 ;; Right: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
+87 ;; __20/50 __20/40 or better
+88 ;; Left: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
+89 ;; __20/50 __20/40 or better
+90 ;;^TOF^
+91 ;; 2. Difference in corrected visual acuity for distance and near vision
+92 ;;
+93 ;; Does the Veteran have a difference equal to two or more lines on the Snellen
+94 ;; test type chart or its equivalent between distance and near corrected
+95 ;; vision, with the near vision being worse?
+96 ;; ___ Yes ___ No
+97 ;; If yes, complete the following section:
+98 ;;
+99 ;; a. Provide a second recording of corrected distance and near vision:
+100 ;; Second recording of corrected distance vision:
+101 ;; Right: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
+102 ;; __20/50 __20/40 or better
+103 ;; Left: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
+104 ;; __20/50 __20/40 or better
+105 ;;
+106 ;; Second recording of corrected near vision:
+107 ;; Right: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
+108 ;; __20/50 __20/40 or better
+109 ;; Left: __5/200 __10/200 __15/200 __20/200 __20/100 __20/70
+110 ;; __20/50 __20/40 or better
+111 ;;
+112 ;; b. Explain reason for the difference between distance and near corrected
+113 ;; vision: ____________________________________________________________________
+114 ;;
+115 ;; c. Does the lens required to correct distance vision in the poorer eye
+116 ;; differ by more than 3 diopters from the lens required to correct distance
+117 ;; vision in the better eye?
+118 ;; ___ Yes ___ No
+119 ;; If yes, explain reason for the difference: _________________________________
+120 ;;
+121 ;; 3. Pupils
+122 ;;
+123 ;; a. Pupil diameter: Right: _____mm Left: _____mm
+124 ;;
+125 ;; b. ___ Pupils are round and reactive to light
+126 ;;
+127 ;; c. Is an afferent pupillary defect present?
+128 ;;___ Yes ___ No
+129 ;; If yes, indicate eye: ___ Right ___ Left
+130 ;;
+131 ;; d. ___ Other, describe: ____________________________________________________
+132 ;; Eye affected: ___ Right ___ Left ___ Both
+133 ;;^TOF^
+134 ;; 4. Anatomical loss, light perception only, extremely poor vision or
+135 ;; blindness
+136 ;;
+137 ;; Does the Veteran have anatomical loss, light perception only, extremely
+138 ;; poor vision or blindness of either eye?
+139 ;; ___ Yes ___ No
+140 ;; If yes, complete the following section:
+141 ;;
+142 ;; a. Does the Veteran have anatomical loss of either eye?
+143 ;; ___ Yes ___ No
+144 ;; If yes, indicate eye:
+145 ;; ___ Right ___ Left ___ Both
+146 ;; If yes, is Veteran able to wear an ocular prosthesis?
+147 ;; ___ Yes ___ No
+148 ;; If no, provide reason: _____________________________________________________
+149 ;;
+150 ;; b. Is the Veteran's vision limited to no more than light perception only
+151 ;; in either eye?
+152 ;; ___ Yes ___ No
+153 ;; If yes, indicate for which eye(s) the Veteran's vision limited to no more
+154 ;; than light perception:
+155 ;; ___ Right ___ Left ___ Both
+156 ;;
+157 ;; c. Is the Veteran able to recognize test letters at 1 foot or closer?
+158 ;; ___ Yes ___ No
+159 ;; If no, indicate with which eye(s) the Veteran is unable to recognize test
+160 ;; letters at 1 foot or closer:
+161 ;; ___ Right ___ Left ___ Both
+162 ;;
+163 ;; d. Is the Veteran able to perceive objects, hand movements, or count fingers
+164 ;; at 3 feet?
+165 ;; ___ Yes ___ No
+166 ;; If no, indicate with which eye(s) the Veteran is unable to perceive objects,
+167 ;; hand movements, or count fingers at 3 feet:
+168 ;; ___ Right ___ Left ___ Both
+169 ;;
+170 ;; e. Does the Veteran have visual acuity of 20/200 or less in the better eye
+171 ;; with use of a correcting lens based upon visual acuity loss (i.e. USA
+172 ;; statutory blindness with bilateral visual acuity of 20/200 or less)?
+173 ;; ___ Yes ___ No
+174 ;;
+175 ;;^TOF^
+176 ;; 5. Astigmatism
+177 ;;
+178 ;; Does the Veteran have a corneal irregularity that results in severe
+179 ;; irregular astigmatism?
+180 ;; ___ Yes ___ No
+181 ;; If yes, complete the following section:
+182 ;;
+183 ;; a. Does the Veteran customarily wear contact lenses to correct the above
+184 ;; corneal irregularity?
+185 ;; ___ Yes ___ No
+186 ;; If yes, does using contact lenses result in more visual improvement than
+187 ;; using the standard spectacle correction?
+188 ;; ___ Yes ___ No
+189 ;;
+190 ;; b. Was the corrected visual acuity determined using contact lenses?
+191 ;; ___ Yes ___ No
+192 ;; If no, explain: ____________________________________________________________
+193 QUIT
