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Routine: DVBCQEY3

DVBCQEY3.m

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