Home   Package List   Routine Alphabetical List   Global Alphabetical List   FileMan Files List   FileMan Sub-Files List   Package Component Lists   Package-Namespace Mapping  
Routine: DVBCQEY3

DVBCQEY3.m

Go to the documentation of this file.
DVBCQEY3 ;;ALB-CIOFO/ECF - EYE CONDITIONS QUESTIONNAIRE ; 6/15/2011
 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
 ;
TXT ;
 ;;
 ;; 6. Diplopia
 ;;
 ;; Does the Veteran have diplopia (double vision)?
 ;; ___ Yes   ___ No
 ;; If yes, complete the following section:
 ;;
 ;; a. Provide etiology (such as traumatic injury, thyroid eye disease,
 ;; myasthenia gravis, etc.): __________________________________________________
 ;; b. The areas of diplopia must be documented on a Goldmann perimeter chart
 ;; that identifies the four major quadrants (upward, downward, left lateral and
 ;; right lateral) and the central field (20 degrees or less). Include the chart
 ;; with this Questionnaire.
 ;; Report the results from the Goldmann perimeter chart below:
 ;;
 ;; Indicate the areas where diplopia is present (the fields in which the
 ;; Veteran sees double using binocular vision):
 ;;    ___ Central 20 degrees
 ;;    ___ 21 to 30 degrees
 ;;        ___ Down
 ;;        ___ Lateral
 ;;        ___ Up
 ;;   ___ 31 to 40 degrees
 ;;        ___ Down
 ;;        ___ Lateral
 ;;        ___ Up
 ;;   ___ Greater than 40 degrees
 ;;        ___ Down
 ;;        ___ Lateral
 ;;        ___ Up
 ;;^TOF^
 ;; c. Indicate frequency of the diplopia:
 ;; ___ Constant   ___ Occasional
 ;; If occasional, indicate frequency of diplopia and most recent occurrence:
 ;; ____________________________________________________________________________
 ;;
 ;; d. Is the diplopia correctable with standard spectacle correction?
 ;; ___ Yes   ___ No
 ;; If no, is the diplopia correctable with standard spectacle correction that
 ;; includes a special prismatic correction?
 ;; ___ Yes   ___ No
 ;;
 ;; 7. Tonometry
 ;;
 ;; a. If tonometry was performed, provide results:
 ;; Right eye pressure: ___________    Left eye pressure: ___________
 ;;
 ;; b. Tonometry method used:
 ;; ___ Goldmann applanation
 ;; ___ Other, describe: _______________________________________________________
 ;;
 ;; 8. Slit lamp and external eye exam
 ;;
 ;; a. External exam/lids/lashes: 
 ;;    Right    ___ Normal   ___ Other, describe: ______________________________
 ;;    Left     ___ Normal   ___ Other, describe: ______________________________
 ;; b. Conjunctiva/sclera:
 ;;    Right    ___ Normal   ___ Other, describe: ______________________________
 ;;    Left     ___ Normal   ___ Other, describe: ______________________________
 ;; c. Cornea:
 ;;    Right    ___ Normal   ___ Other, describe: ______________________________
 ;;    Left     ___ Normal   ___ Other, describe: ______________________________
 ;; d. Anterior chamber
 ;;    Right    ___ Normal   ___ Other, describe: ______________________________
 ;;    Left     ___ Normal   ___ Other, describe: ______________________________
 ;; e. Iris:
 ;;    Right    ___ Normal   ___ Other, describe: ______________________________
 ;;    Left     ___ Normal   ___ Other, describe: ______________________________
 ;; f. Lens:
 ;;    Right    ___ Normal   ___ Other, describe: ______________________________
 ;;    Left     ___ Normal   ___ Other, describe: ______________________________
 ;;^TOF^
 ;; 9. Internal eye exam (fundus)
 ;;
 ;; Fundus:
 ;;     ___ Normal bilaterally
 ;;     ___ Abnormal
 ;; If checked, complete the following section:
 ;; a. Optic disc:
 ;;    Right    ___ Normal   ___ Other, describe: ______________________________
 ;;    Left     ___ Normal   ___ Other, describe: ______________________________
 ;; b. Macula:
 ;;    Right    ___ Normal   ___ Other, describe: ______________________________
 ;;    Left     ___ Normal   ___ Other, describe: ______________________________
 ;; c. Vessels
 ;;    Right    ___ Normal   ___ Other, describe: ______________________________
 ;;    Left     ___ Normal   ___ Other, describe: ______________________________
 ;; d. Vitreous:
 ;;    Right    ___ Normal   ___ Other, describe: ______________________________
 ;;    Left     ___ Normal   ___ Other, describe: ______________________________
 ;; e. Periphery:
 ;;    Right    ___ Normal   ___ Other, describe: ______________________________
 ;;    Left     ___ Normal   ___ Other, describe: ______________________________
 ;;
 ;; 10. Visual fields
 ;;
 ;; Does the Veteran have a visual field defect (or a condition that may result
 ;; in visual field defect)?
 ;; ___ Yes   ___ No
 ;; If yes, complete the following section:
 ;; 
 ;; NOTE: For VA purposes, examiners must perform visual field testing using
 ;; either Goldmann kinetic perimetry or automated perimetry using Humphrey
 ;; Model 750, Octopus Model 101 or later versions of these perimetric devices
 ;; with simulated kinetic Goldmann testing capability. The results must be
 ;; recorded on a standard Goldmann chart providing at least 16 meridians 22 1/2
 ;; degrees apart for each eye and included with this Questionnaire.
 ;;
 ;; If additional testing is necessary to evaluate visual fields, it must be
 ;; conducted using either a tangent screen or a 30-degree threshold visual
 ;; field with the Goldmann III stimulus size. The examination report must then
 ;; include the tracing of either the tangent screen or of the 30-degree
 ;; threshold visual field with the Goldmann III stimulus size.
 ;;^TOF^
 ;; a. Was visual field testing performed?
 ;; ___ Yes   ___ No
 ;; Results:
 ;; ___ Using Goldmann's equivalent III/4e target
 ;; ___ Using Goldmann's equivalent IV/4e target (used for aphakic individuals
 ;;     not well adapted to contact lens correction or pseudophakic individuals
 ;;     not well adapted to intraocular lens implant)
 ;; ___ Other, describe: _______________________________________________________
 ;;
 ;; b. Does the Veteran have contraction of a visual field?
 ;; ___ Yes   ___ No
 ;; If yes, include Goldmann chart with this Questionnaire.
 ;;
 ;; c. Does the Veteran have loss of a visual field?
 ;; ___ Yes   ___ No
 ;; If yes, check all that apply and indicate eye affected:
 ;;
 ;; ___ Homonymous hemianopsia                 ___ Right   ___ Left   ___ Both
 ;; ___ Loss of temporal half of visual field  ___ Right   ___ Left   ___ Both
 ;; ___ Loss of nasal half of visual field     ___ Right   ___ Left   ___ Both
 ;; ___ Loss of inferior half of visual field  ___ Right   ___ Left   ___ Both
 ;; ___ Loss of superior half of visual field  ___ Right   ___ Left   ___ Both
 ;; ___ Other, specify:  _____________________________________________________
 ;;                                            ___ Right   ___ Left   ___ Both
 ;;
 ;; d. Does the Veteran have a scotoma?
 ;; ___ Yes   ___ No
 ;; If yes, check all that apply and indicate eye affected:
 ;;    ___ Scotoma affecting at least 1/4 of the visual field
 ;;        ___ Right   ___ Left   ___ Both
 ;;    ___ Centrally located scotoma
 ;;        ___ Right   ___ Left   ___ Both
 ;;
 ;; e. Does the Veteran have legal (statutory) blindness (visual field diameter
 ;; of 20 degrees or less in the better eye, even  if the corrected visual
 ;; acuity is 20/20) based upon visual field loss?
 ;; ___ Yes   ___ No
 ;;^TOF^
 ;; SECTION IV: Eye conditions
 ;;
 ;; 1. Conditions
 ;;
 ;; Does the Veteran have any of the following eye conditions?
 ;; ___ Yes   ___ No
 ;; If no, proceed to Section V.
 ;; If yes, check all that apply:
 ;; ___ Anatomical loss of eyelids,
 ;;     brows, lashes               (If checked, complete # 2 below)
 ;; ___ Lacrimal gland and lid
 ;;     disorders (other than
 ;;     ptosis or anatomic loss)    (If checked, complete # 3 below)
 ;; ___ Ptosis, for either or both
 ;;     eyelids                     (If checked, complete # 4 below)
 ;; ___ Conjunctivitis and other
 ;;     conjunctival conditions     (If checked, complete # 5 below)
 ;; ___ Corneal conditions          (If checked, complete # 6 below)
 ;; ___ Cataract and other lens
 ;;     conditions                  (If checked, complete # 7 below)
 ;; ___ Inflammatory eye conditions
 ;;     and/or injuries             (If checked, complete # 8 below)
 ;; ___ Glaucoma                    (If checked, complete # 9 below)
 ;; ___ Optic neuropathy and other
 ;;     disc conditions             (If checked, complete # 10 below)
 ;; ___ Retinal conditions          (If checked, complete # 11 below)
 ;; ___ Neurologic eye conditions   (If checked, complete # 12 below)
 ;; ___ Tumors and neoplasms        (If checked, complete # 13 below)
 ;; ___ Other eye conditions        (If checked, complete # 14 below)
 ;;
 ;; For each checked answer, complete the appropriate section (2-14) below:
 ;;
 ;; 2. Anatomical loss of eyelids, brows, lashes
 ;;
 ;; a. Indicate condition and side affected (check all that apply):
 ;; ___ Partial or complete loss of eyelid
 ;;     Side affected:   ___ Right   ___ Left   ___ Both
 ;; ___ Complete loss of eyebrows
 ;;     Side affected:   ___ Right   ___ Left   ___ Both
 ;; ___ Complete loss of eyelashes
 ;;     Side affected:   ___ Right   ___ Left   ___ Both
 ;;
 ;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
 ;; if present, attributable to eyelid loss?
 ;; ___ Yes   ___ No     ___ There is no decrease in visual acuity or other
 ;; visual impairment
 ;; If no, explain: ____________________________________________________________
 ;;^TOF^
 ;; c. If present, does eyelid loss cause scarring or disfigurement?
 ;; ___ Yes   ___ No
 ;; If yes, complete Section IV, Scarring and disfigurement.
 ;;
 ;; 3. Lacrimal gland and lid conditions
 ;;
 ;; Indicate the Veteran's condition(s) and side affected (check all that apply):
 ;; ___ Ectropion         Side affected:  ___ Right   ___ Left   ___ Both
 ;; ___ Entropion         Side affected:  ___ Right   ___ Left   ___ Both
 ;; ___ Lagophthalmos     Side affected:  ___ Right   ___ Left   ___ Both
 ;; ___ Disorder of the lacrimal apparatus (epiphora, dacryocystitis, etc.)
 ;;     If checked, specify condition: _________________________________________
 ;;                       Side affected:  ___ Right   ___ Left   ___ Both
 ;;
 ;; c. If present, does lacrimal or lid condition cause scarring or
 ;; disfigurement?
 ;; ___ Yes   ___ No
 ;; If yes, complete Section IV, Scarring and disfigurement.
 ;;
 ;; 4. Ptosis
 ;;
 ;; a. If ptosis is present, indicate side affected:
 ;; ___ Right   ___ Left   ___ Both
 ;;
 ;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
 ;; if present, attributable to ptosis?
 ;; ___ Yes   ___ No   ___ There is no decrease in visual acuity or other visual
 ;;                        impairment
 ;; If no, explain: ____________________________________________________________
 ;; 
 ;; c. Does the ptosis cause disfigurement?
 ;; ___ Yes   ___ No
 ;; If yes, complete Section IV, Scarring and disfigurement.
 ;;
 ;; 5. Conjunctivitis and other conjunctival conditions
 ;;
 ;; a. Indicate type of conjunctivitis, activity, and side affected (check
 ;; all that apply):
 ;; ___ Trachomatous:
 ;;     ___ Active      Eye affected:   ___ Right   ___ Left   ___ Both
 ;;     ___ Inactive    Eye affected:   ___ Right   ___ Left   ___ Both
 ;; ___ Nontrachomatous:
 ;;     ___ Active      Eye affected:   ___ Right   ___ Left   ___ Both
 ;;     ___ Inactive    Eye affected:   ___ Right   ___ Left   ___ Both
 ;;^TOF^
 ;; b. Indicate the Veteran's other conjunctival conditions, if any (check
 ;; all that apply):
 ;; ___ Pinguecula      Eye affected:   ___ Right   ___ Left   ___ Both
 ;; ___ Symblepharon    Eye affected:   ___ Right   ___ Left   ___ Both
 ;; ___ Other, describe: _______________________________________________________
 ;;                     Eye affected:   ___ Right   ___ Left   ___ Both
 ;;
 ;; c. Is the Veteran's decrease in visual acuity or other visual impairment, if
 ;; present, attributable to any of the eye conditions checked above in this
 ;; section?
 ;; ___ Yes   ___ No   ___ There is no decrease in visual acuity or other visual
 ;;                        impairment
 ;; If no, explain: ____________________________________________________________
 ;;
 ;; d. Does any eye condition identified in this section cause scarring or
 ;; disfigurement?
 ;; ___ Yes   ___ No
 ;; If yes, complete Section IV, Scarring and disfigurement.
 ;;
 ;; 6. Corneal conditions
 ;;
 ;; a. Has the Veteran had a corneal transplant?
 ;; ___ Yes   ___ No
 ;; If yes, indicate side of transplant:   ___ Right   ___ Left   ___ Both
 ;; Indicate residuals (check all that apply):
 ;; ___ Pain                Eye affected:  ___ Right   ___ Left   ___ Both
 ;; ___ Photophobia         Eye affected:  ___ Right   ___ Left   ___ Both
 ;; ___ Glare sensitivity   Eye affected:  ___ Right   ___ Left   ___ Both
 ;; ___ Other, describe: _______________________________________________________
 ;;                         Eye affected:  ___ Right   ___ Left   ___ Both
 ;;
 ;; b. Does the Veteran have keratoconus?
 ;; ___ Yes   ___ No
 ;; If yes, indicate eye affected:  ___ Right   ___ Left   ___ Both
 ;;
 ;; c. Does the Veteran have a pterygium?
 ;; ___ Yes   ___ No
 ;; If yes, indicate eye affected:  ___ Right   ___ Left   ___ Both
 ;;
 ;; d. Does the Veteran have another corneal condition that may result in an
 ;; irregular cornea?
 ;; (For example, pellucid marginal degeneration, irregular astigmatism from
 ;; corneal scar, post-laser refractive surgery, acne rosacea keratopathy, etc.)
 ;; ___ Yes   ___ No
 ;; If yes, specify corneal condition: _________________________________________
 ;;    Eye affected:  ___ Right   ___ Left   ___ Both
 ;;^TOF^
 ;; e. Is the Veteran's decrease in visual acuity or other visual impairment, if
 ;; present, attributable to keratoconus or another corneal condition, if
 ;; present?
 ;; ___ Yes   ___ No   ___ There is no decrease in visual acuity or other
 ;;                        visual impairment
 ;; If yes, specify corneal condition responsible for visual impairment
 ;; ___________________________________________________________________________.
 ;; If no, explain: ____________________________________________________________
 ;;
 ;; f. Does any eye condition identified in this section cause scarring or
 ;; disfigurement?
 ;; ___ Yes   ___ No
 ;; If yes, complete Section IV, Scarring and disfigurement.
 ;; 
 Q