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Routine: DVBCQEY2

DVBCQEY2.m

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  1. DVBCQEY2 ;;ALB-CIOFO/ECF -  EYE CONDITIONS QUESTIONNAIRE ; 6/15/2011
  1.  ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA)
  1.  ;; for disability benefits.  VA will consider the information you provide on
  1.  ;; this questionnaire as part of their evaluation in processing the Veteran's
  1.  ;; claim.  This report is not for treatment purposes; it is to provide a
  1.  ;; summary of medical information for disability claims resolution.
  1.  ;;
  1.  ;; NOTE: This examination must be conducted by a licensed ophthalmologist or
  1.  ;; by a licensed optometrist. The examiner must identify the disease, injury
  1.  ;; or other pathologic process responsible for any decrease in visual acuity
  1.  ;; or other visual impairment found.
  1.  ;;
  1.  ;; Examinations of visual fields or muscle function should be conducted ONLY
  1.  ;; when there is a medical indication of disease or injury that may be
  1.  ;; associated with visual field defect or impaired muscle function.
  1.  ;;
  1.  ;; Unless medically contraindicated, the fundus must be examined with the
  1.  ;; Veteran's pupils dilated.
  1.  ;;
  1.  ;; SECTION I: DIAGNOSES
  1.  ;;
  1.  ;; NOTE: The diagnosis section should be filled out AFTER the clinician has
  1.  ;; completed the examination
  1.  ;;
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with an eye
  1.  ;; condition (other than congenital or developmental errors of refraction)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide only diagnoses that pertain to eye conditions:
  1.  ;;
  1.  ;; Diagnosis #1: ___________________
  1.  ;; ICD code(s):  ___________________
  1.  ;; Date of diagnosis: ______________
  1.  ;;
  1.  ;; Diagnosis #2: ___________________
  1.  ;; ICD code(s):  ___________________
  1.  ;; Date of diagnosis: ______________
  1.  ;;
  1.  ;; Diagnosis #3: ___________________
  1.  ;; ICD code(s):  ___________________
  1.  ;; Date of diagnosis: ______________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to eye conditions, list using
  1.  ;; above format: ______________________________________________________________
  1.  ;;^TOF^
  1.  ;; SECTION II: MEDICAL HISTORY
  1.  ;;
  1.  ;; Describe the history (including onset and course) of the Veteran's current
  1.  ;; eye condition(s) (brief summary):
  1.  ;;
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; SECTION III: PHYSICAL EXAMINATION
  1.  ;;
  1.  ;; 1. Visual acuity
  1.  ;;
  1.  ;; Visual acuity should be reported according to the lines on the Snellen chart
  1.  ;; or its equivalent. If assessment of the Veteran's visual acuity falls
  1.  ;; between two lines on the Snellen chart, round up to the higher (worse) level
  1.  ;; (poorer vision) for answers a-d below. (For example, 20/60 would be reported
  1.  ;; as 20/70; 20/80 would be reported as 20/100, etc.)
  1.  ;;
  1.  ;; Examination of visual acuity must include central uncorrected and corrected
  1.  ;; visual acuity for distance and near vision. Evaluate central visual acuity
  1.  ;; on the basis of corrected distance vision with central fixation. Visual
  1.  ;; acuity should not be determined with eccentric fixation or viewing.  
  1.  ;;
  1.  ;; a. Uncorrected distance:
  1.  ;;    Right: __5/200    __10/200    __15/200   __20/200   __20/100   __20/70
  1.  ;;           __20/50    __20/40 or better
  1.  ;;    Left:  __5/200    __10/200    __15/200   __20/200   __20/100   __20/70
  1.  ;;           __20/50    __20/40 or better
  1.  ;;
  1.  ;; b. Uncorrected near:
  1.  ;;    Right: __5/200    __10/200    __15/200   __20/200   __20/100   __20/70
  1.  ;;           __20/50    __20/40 or better
  1.  ;;    Left:  __5/200    __10/200    __15/200   __20/200   __20/100   __20/70
  1.  ;;           __20/50    __20/40 or better
  1.  ;;
  1.  ;; c. Corrected distance:
  1.  ;;    Right: __5/200    __10/200    __15/200   __20/200   __20/100   __20/70
  1.  ;;           __20/50    __20/40 or better
  1.  ;;    Left:  __5/200    __10/200    __15/200   __20/200   __20/100   __20/70
  1.  ;;           __20/50    __20/40 or better
  1.  ;;
  1.  ;; d. Corrected near:
  1.  ;;    Right: __5/200    __10/200    __15/200   __20/200   __20/100   __20/70
  1.  ;;           __20/50    __20/40 or better
  1.  ;;    Left:  __5/200    __10/200    __15/200   __20/200   __20/100   __20/70
  1.  ;;           __20/50    __20/40 or better
  1.  ;;^TOF^
  1.  ;; 2. Difference in corrected visual acuity for distance and near vision
  1.  ;;
  1.  ;; Does the Veteran have a difference equal to two or more lines on the Snellen
  1.  ;; test type chart or its equivalent between distance and near corrected
  1.  ;; vision, with the near vision being worse?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete the following section:
  1.  ;;
  1.  ;; a. Provide a second recording of corrected distance and near vision:
  1.  ;; Second recording of corrected distance vision:
  1.  ;;    Right: __5/200    __10/200    __15/200   __20/200   __20/100   __20/70
  1.  ;;           __20/50    __20/40 or better
  1.  ;;    Left:  __5/200    __10/200    __15/200   __20/200   __20/100   __20/70
  1.  ;;           __20/50    __20/40 or better
  1.  ;;
  1.  ;; Second recording of corrected near vision:
  1.  ;;    Right: __5/200    __10/200    __15/200   __20/200   __20/100   __20/70
  1.  ;;           __20/50    __20/40 or better
  1.  ;;    Left:  __5/200    __10/200    __15/200   __20/200   __20/100   __20/70
  1.  ;;           __20/50    __20/40 or better
  1.  ;;
  1.  ;; b. Explain reason for the difference between distance and near corrected
  1.  ;; vision: ____________________________________________________________________
  1.  ;;
  1.  ;; c. Does the lens required to correct distance vision in the poorer eye
  1.  ;; differ by more than 3 diopters from the lens required to correct distance
  1.  ;; vision in the better eye?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, explain reason for the difference: _________________________________
  1.  ;;
  1.  ;; 3. Pupils
  1.  ;;
  1.  ;; a. Pupil diameter: Right: _____mm       Left: _____mm
  1.  ;;
  1.  ;; b. ___ Pupils are round and reactive to light
  1.  ;;    
  1.  ;; c. Is an afferent pupillary defect present?
  1.  ;;___ Yes   ___ No
  1.  ;; If yes, indicate eye: ___ Right   ___ Left
  1.  ;;
  1.  ;; d. ___ Other, describe: ____________________________________________________
  1.  ;; Eye affected:  ___ Right   ___ Left   ___ Both
  1.  ;;^TOF^
  1.  ;; 4. Anatomical loss, light perception only, extremely poor vision or
  1.  ;; blindness
  1.  ;;
  1.  ;; Does the Veteran have anatomical loss, light perception only, extremely
  1.  ;; poor vision or blindness of either eye?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete the following section:
  1.  ;;
  1.  ;; a. Does the Veteran have anatomical loss of either eye?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate eye:
  1.  ;;   ___ Right   ___ Left   ___ Both
  1.  ;; If yes, is Veteran able to wear an ocular prosthesis?
  1.  ;; ___ Yes   ___ No
  1.  ;; If no, provide reason: _____________________________________________________
  1.  ;;
  1.  ;; b. Is the Veteran's vision limited to no more than light perception only
  1.  ;; in either eye?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate for which eye(s) the Veteran's vision limited to no more
  1.  ;; than light perception:
  1.  ;; ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; c. Is the Veteran able to recognize test letters at 1 foot or closer?
  1.  ;; ___ Yes   ___ No
  1.  ;; If no, indicate with which eye(s) the Veteran is unable to recognize test
  1.  ;; letters at 1 foot or closer:
  1.  ;; ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; d. Is the Veteran able to perceive objects, hand movements, or count fingers
  1.  ;; at 3 feet?
  1.  ;; ___ Yes   ___ No
  1.  ;; If no, indicate with which eye(s) the Veteran is unable to perceive objects,
  1.  ;; hand movements, or count fingers at 3 feet:
  1.  ;; ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; e. Does the Veteran have visual acuity of 20/200 or less in the better eye
  1.  ;; with use of a correcting lens based upon visual acuity loss (i.e. USA
  1.  ;; statutory blindness with bilateral visual acuity of 20/200 or less)?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;;^TOF^
  1.  ;; 5. Astigmatism
  1.  ;;
  1.  ;; Does the Veteran have a corneal irregularity that results in severe
  1.  ;; irregular astigmatism?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete the following section:
  1.  ;;
  1.  ;; a. Does the Veteran customarily wear contact lenses to correct the above
  1.  ;; corneal irregularity?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, does using contact lenses result in more visual improvement than
  1.  ;; using the standard spectacle correction?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; b. Was the corrected visual acuity determined using contact lenses?
  1.  ;; ___ Yes   ___ No
  1.  ;; If no, explain: ____________________________________________________________
  1.  Q