DVBCQEY4 ;;ALB-CIOFO/ECF - EYE CONDITIONS QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
;
TXT ;
;; 7. Cataract and other lens conditions
;;
;; a. Indicate cataract condition:
;; ___ Preoperative (cataract is present)
;; Eye affected: ___ Right ___ Left ___ Both
;; ___ Postoperative (cataract has been removed)
;; Eye affected: ___ Right ___ Left ___ Both
;; ___ Is there a replacement intraocular lens?
;; ___ Yes ___ No
;; If yes, indicate eye: ___ Right ___ Left ___ Both
;;
;; b. Is there aphakia or dislocation of the crystalline lens?
;; ___ Yes ___ No
;; If yes, indicate eye: ___ 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 yes, specify condition in this section responsible for visual impairment
;; ___________________________________________________________________________.
;; If no, explain: ____________________________________________________________
;;
;; 8. Inflammatory eye conditions and/or injuries
;;
;; a. Indicate the Veteran's condition and eye affected:
;; ___ Choroidopathy (including uveitis,
;; iritis, cyclitis, and choroiditis) ___ Right ___ Left ___ Both
;; ___ Keratopathy ___ Right ___ Left ___ Both
;; ___ Scleritis ___ Right ___ Left ___ Both
;; ___ Intraocular hemorrhage ___ Right ___ Left ___ Both
;; ___ Unhealed eye injury ___ Right ___ Left ___ Both
;; ___ Other, describe: _______________________________________________________
;; ___ Right ___ Left ___ Both
;;^TOF^
;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
;; if present, attributable to any eye condition checked above in this section?
;; ___ Yes ___ No ___ There is no decrease in visual acuity or other visual
;; impairment
;; If yes, specify inflammatory or traumatic condition responsible for visual
;; impairment ________________________________________________________________.
;; If no, explain: ____________________________________________________________
;;
;; c. Does any eye condition identified in this section cause scarring or
;; disfigurement?
;; ___ Yes ___ No
;; If yes, complete Section IV, Scarring and disfigurement.
;;
;; 9. Glaucoma
;;
;; a. Specify the type of glaucoma:
;; ___ Angle-closure Eye affected: ___ Right ___ Left ___ Both
;; ___ Open-angle Eye affected: ___ Right ___ Left ___ Both
;; ___ Other, specify type (For example, neovascular, phakolytic, etc.)
;; ________________________________________________________________________
;; Eye affected: ___ Right ___ Left ___ Both
;;
;; b. Does the glaucoma require continuous medication for treatment?
;; ___ Yes ___ No
;; If yes, indicate eye affected: ___ Right ___ Left ___ Both
;; List medication(s) used for treatment of glaucoma: _________________________
;;
;; c. Is the Veteran's decrease in visual acuity or other visual impairment,
;; if present, attributable to glaucoma?
;; ___ Yes ___ No ___ There is no decrease in visual acuity or other
;; visual impairment
;; If no, explain: ____________________________________________________________
;;
;; d. Does any glaucoma condition identified in this section cause scarring
;; or disfigurement?
;; ___ Yes ___ No
;; If yes, complete Section IV, Scarring and disfigurement.
;;
;; 10. Optic neuropathy and other disc conditions
;;
;; a. Indicate optic neuropathy and other disc conditions, and eye affected:
;; (check all that apply)
;; ___ Drusen of optic disc ___ Right ___ Left ___ Both
;; ___ Ischemic optic neuropathy ___ Right ___ Left ___ Both
;; ___ Nutritional optic neuropathy ___ Right ___ Left ___ Both
;; ___ Optic atrophy ___ Right ___ Left ___ Both
;; ___ Other, describe _______________________ ___ Right ___ Left ___ Both
;;^TOF^
;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
;; if present, attributable to any of the above checked eye conditions?
;; ___ Yes ___ No ___ There is no decrease in visual acuity or other
;; visual impairment
;; If yes, specify optic neuropathy or disc condition responsible for visual
;; impairment _________________________________________________________________
;; If no, explain: ____________________________________________________________
;;
;; 11. Retinal conditions
;;
;; a. Indicate retinal condition, and eye affected: (check all that apply)
;;
;; ___ Retinopathy ___ Right ___ Left ___ Both
;; ___ Maculopathy ___ Right ___ Left ___ Both
;; ___ Detached retina ___ Right ___ Left ___ Both
;; ___ Retinal hemorrhage ___ Right ___ Left ___ Both
;; ___ Centrally located retinal scars, atrophy or irregularities in either
;; eye that result in an irregular, duplicated, enlarged or
;; diminished image in either eye ___ Right ___ Left ___ Both
;;
;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
;; if present, attributable to any of the above checked eye conditions?
;; ___ Yes ___ No ___ There is no decrease in visual acuity or other
;; visual impairment
;; If yes, specify retinal condition responsible for visual impairment
;; ____________________________________________________________________________
;;
;; If no, explain: ____________________________________________________________
;;
;; 12. Neurologic eye conditions
;;
;; a. Indicate the Veteran's neurologic eye condition/disorder:
;; ___ Nystagmus
;; If checked, is nystagmus etiology central? ___ Yes ___ No
;; ___ Paresis/paralysis of 3rd cranial nerve (oculomotor)
;; Eye affected: ___ Right ___ Left ___ Both
;; ___ Paresis/paralysis of 4th cranial nerve (trochlear)
;; Eye affected: ___ Right ___ Left ___ Both
;; ___ Paresis/paralysis of 6th cranial nerve (abducens)
;; Eye affected: ___ Right ___ Left ___ Both
;; ___ Paresis/paralysis of 7th cranial nerve (facial, Bell's palsy)
;; Eye affected: ___ Right ___ Left ___ Both
;; ___ Eye condition due to cerebrovascular accident (CVA)
;; If checked, specify eye condition attributable to CVA: _________________
;; Eye affected: ___ Right ___ Left ___ Both
;; ___ Eye condition due to demyelinating disease
;; If checked, specify eye condition attributable to demyelinating
;; disease: _______________________________________________________________
;; Eye affected: ___ Right ___ Left ___ Both
;;^TOF^
;; ___ Optic neuritis
;; Eye affected: ___ Right ___ Left ___ Both
;; ___ Eye condition due to intracranial mass/tumor
;; If checked, specify eye condition attributable to intracranial
;; mass/tumor: ____________________________________________________________
;; Eye affected: ___ Right ___ Left ___ Both
;; ___ Eye disorder due to traumatic brain injury (TBI)
;; If checked, specify eye condition attributable to TBI: _________________
;; Eye affected: ___ Right ___ Left ___ Both
;; ___ Other
;; If checked, specify neurologic eye condition/disorder and name the
;; underlying neurologic condition (for example, Alzheimer's disease,
;; Jakob-Creutzfeldt disease, etc.): __________________________________________
;; Eye affected: ___ Right ___ Left ___ Both
;;
;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
;; if present, attributable to any of the neurologic eye conditions checked
;; above in this section?
;; ___ Yes ___ No ___ There is no decrease in visual acuity or other
;; visual impairment
;; If yes, specify condition in this section responsible for visual impairment
;; ___________________________________________________________________________.
;; If no, explain: ____________________________________________________________
;;
;; 13. Tumors and neoplasms
;;
;; Does the Veteran have a benign or malignant neoplasm or metastases related
;; to any of the diagnoses in the Diagnosis section?
;; ___ Yes ___ No
;; If yes, complete the following:
;;
;; a. Is the neoplasm:
;; ___ Benign ___ Malignant
;;
;; b. Has the Veteran completed treatment or is the Veteran currently
;; undergoing treatment for a benign or malignant neoplasm or metastases?
;; ___ Yes ___ No watchful waiting
;; If yes, indicate type of treatment the Veteran is currently undergoing
;; or has completed (check all that apply):
;; ___ Treatment completed; currently in watchful waiting status
;; ___ Surgery
;; If checked, describe: ____________________
;; Date(s) of surgery: ______________________
;; ___ Radiation therapy
;; Date of most recent treatment: ___________
;; Date of completion of treatment or anticipated date of
;; completion: ______________________________
;;^TOF^
;; ___ Antineoplastic chemotherapy
;; Date of most recent treatment: ___________
;; Date of completion of treatment or anticipated date of
;; completion:______________________________
;; ___ Other therapeutic procedure
;; If checked, describe procedure: ___________________
;; Date of most recent procedure: ____________________
;; ___ Other therapeutic treatment
;; If checked, describe treatment:
;; Date of completion of treatment or anticipated date of
;; completion:____________________
;;
;; c. Does the Veteran currently have any residual conditions or complications
;; due to the neoplasm (including metastases) or its treatment, other than
;; those already documented in the report above?
;; ___ Yes ___ No
;; If yes, list residual conditions and complications (brief summary):
;;_____________________________________________________________________________
;;
;; d. If there are additional benign or malignant neoplasms or metastases
;; related to any of the diagnoses in the Diagnosis section, describe using
;; the above format: __________________________________________________________
;;
;; e. Does any benign or malignant neoplasms or metastases identified in this
;; section cause scarring or disfigurement?
;; ___ Yes ___ No
;; If yes, complete Section IV, Scarring and disfigurement.
;;
;; 14. Other eye conditions, pertinent physical findings, complications,
;; conditions, signs and/or symptoms
;;
;; Does the Veteran have any other eye conditions, pertinent physical findings,
;; complications, conditions, signs and/or symptoms related to the condition
;; at hand?
;; ___ Yes ___ No
;; If yes, describe: __________________________________________________________
;;^TOF^
;; SECTION V: Scarring and disfigurement
;;
;; Does the Veteran have scarring or disfigurement attributable to any eye
;; condition?
;; ___ Yes ___ No
;; If yes, indicate scar attributes (check all that apply):
;; ___ Scar at least one-quarter inch (0.6 cm.) wide at widest part
;; ___ Surface contour of scar elevated or depressed on palpation (or
;; inspection in the case of cornea or sclera)
;; ___ Scar adherent to underlying tissue (including eyelids adherent to
;; scleral tissue)
;; ___ Visible or palpable tissue loss
;; ___ Gross distortion or asymmetry of one feature or paired set of
;; features (eyes)
;;
;; For all checked conditions, describe scarring and/or disfigurement:
;;_____________________________________________________________________________
;;
;; NOTE: If possible, include color photographs with any report of scarring
;; or disfigurement.
;;
;; SECTION VI: Incapacitating episodes
;;
;; During the past 12 months, has the Veteran had any incapacitating episodes
;; attributable to any eye conditions?
;; NOTE: For VA purposes, an incapacitating episode is a period of acute
;; symptoms severe enough to require prescribed bed rest and treatment by a
;; physician or other healthcare provider (For example, temporary bed rest
;; required for a retinal condition.)
;; ___ Yes ___ No
;; If yes, specify the eye condition(s) causing incapacitating episodes:
;; ____________________________________________________________________________
;;
;; Describe how the eye condition(s) caused incapacitating episodes:
;; ____________________________________________________________________________
;;
;; Provide the total duration for the incapacitating episodes for all
;; incapacitating conditions over the past 12 months:
;; ___ Less than 1 week
;; ___ At least 1 week but less than 2 weeks
;; ___ At least 2 weeks but less than 4 weeks
;; ___ At least 4 weeks but less than 6 weeks
;; ___ At least 6 weeks
;;^TOF^
;; SECTION VII
;;
;; 1. Functional impact
;;
;; Does the Veteran's eye condition(s) impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's eye condition(s),
;; providing one or more examples: ____________________________________________
;;
;; 2. Remarks, if any: ________________________________________________________
;;
;; Optometrist/Physician signature: __________________ Date: __________________
;;
;; Optometrist/Physician printed name: ________________________________________
;;
;; Optometric/Medical license #: ______________________________________________
;;
;; State of licensure: ________________________________________________________
;;
;; Optometrist/Physician address: _____________________________________________
;;
;; Phone: ________________________ Fax: _______________________________________
;;
;; NOTE: VA may request additional medical information, including additional
;; examinations if necessary to complete VA's review of the Veteran's
;; application.
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQEY4 14740 printed Apr 09, 2024@20:51:39 Page 2
DVBCQEY4 ;;ALB-CIOFO/ECF - EYE CONDITIONS QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;; 7. Cataract and other lens conditions
+2 ;;
+3 ;; a. Indicate cataract condition:
+4 ;; ___ Preoperative (cataract is present)
+5 ;; Eye affected: ___ Right ___ Left ___ Both
+6 ;; ___ Postoperative (cataract has been removed)
+7 ;; Eye affected: ___ Right ___ Left ___ Both
+8 ;; ___ Is there a replacement intraocular lens?
+9 ;; ___ Yes ___ No
+10 ;; If yes, indicate eye: ___ Right ___ Left ___ Both
+11 ;;
+12 ;; b. Is there aphakia or dislocation of the crystalline lens?
+13 ;; ___ Yes ___ No
+14 ;; If yes, indicate eye: ___ Right ___ Left ___ Both
+15 ;;
+16 ;; c. Is the Veteran's decrease in visual acuity or other visual impairment,
+17 ;; if present, attributable to any of the eye conditions checked above in this
+18 ;; section?
+19 ;; ___ Yes ___ No ___ There is no decrease in visual acuity or other visual
+20 ;; impairment
+21 ;; If yes, specify condition in this section responsible for visual impairment
+22 ;; ___________________________________________________________________________.
+23 ;; If no, explain: ____________________________________________________________
+24 ;;
+25 ;; 8. Inflammatory eye conditions and/or injuries
+26 ;;
+27 ;; a. Indicate the Veteran's condition and eye affected:
+28 ;; ___ Choroidopathy (including uveitis,
+29 ;; iritis, cyclitis, and choroiditis) ___ Right ___ Left ___ Both
+30 ;; ___ Keratopathy ___ Right ___ Left ___ Both
+31 ;; ___ Scleritis ___ Right ___ Left ___ Both
+32 ;; ___ Intraocular hemorrhage ___ Right ___ Left ___ Both
+33 ;; ___ Unhealed eye injury ___ Right ___ Left ___ Both
+34 ;; ___ Other, describe: _______________________________________________________
+35 ;; ___ Right ___ Left ___ Both
+36 ;;^TOF^
+37 ;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
+38 ;; if present, attributable to any eye condition checked above in this section?
+39 ;; ___ Yes ___ No ___ There is no decrease in visual acuity or other visual
+40 ;; impairment
+41 ;; If yes, specify inflammatory or traumatic condition responsible for visual
+42 ;; impairment ________________________________________________________________.
+43 ;; If no, explain: ____________________________________________________________
+44 ;;
+45 ;; c. Does any eye condition identified in this section cause scarring or
+46 ;; disfigurement?
+47 ;; ___ Yes ___ No
+48 ;; If yes, complete Section IV, Scarring and disfigurement.
+49 ;;
+50 ;; 9. Glaucoma
+51 ;;
+52 ;; a. Specify the type of glaucoma:
+53 ;; ___ Angle-closure Eye affected: ___ Right ___ Left ___ Both
+54 ;; ___ Open-angle Eye affected: ___ Right ___ Left ___ Both
+55 ;; ___ Other, specify type (For example, neovascular, phakolytic, etc.)
+56 ;; ________________________________________________________________________
+57 ;; Eye affected: ___ Right ___ Left ___ Both
+58 ;;
+59 ;; b. Does the glaucoma require continuous medication for treatment?
+60 ;; ___ Yes ___ No
+61 ;; If yes, indicate eye affected: ___ Right ___ Left ___ Both
+62 ;; List medication(s) used for treatment of glaucoma: _________________________
+63 ;;
+64 ;; c. Is the Veteran's decrease in visual acuity or other visual impairment,
+65 ;; if present, attributable to glaucoma?
+66 ;; ___ Yes ___ No ___ There is no decrease in visual acuity or other
+67 ;; visual impairment
+68 ;; If no, explain: ____________________________________________________________
+69 ;;
+70 ;; d. Does any glaucoma condition identified in this section cause scarring
+71 ;; or disfigurement?
+72 ;; ___ Yes ___ No
+73 ;; If yes, complete Section IV, Scarring and disfigurement.
+74 ;;
+75 ;; 10. Optic neuropathy and other disc conditions
+76 ;;
+77 ;; a. Indicate optic neuropathy and other disc conditions, and eye affected:
+78 ;; (check all that apply)
+79 ;; ___ Drusen of optic disc ___ Right ___ Left ___ Both
+80 ;; ___ Ischemic optic neuropathy ___ Right ___ Left ___ Both
+81 ;; ___ Nutritional optic neuropathy ___ Right ___ Left ___ Both
+82 ;; ___ Optic atrophy ___ Right ___ Left ___ Both
+83 ;; ___ Other, describe _______________________ ___ Right ___ Left ___ Both
+84 ;;^TOF^
+85 ;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
+86 ;; if present, attributable to any of the above checked eye conditions?
+87 ;; ___ Yes ___ No ___ There is no decrease in visual acuity or other
+88 ;; visual impairment
+89 ;; If yes, specify optic neuropathy or disc condition responsible for visual
+90 ;; impairment _________________________________________________________________
+91 ;; If no, explain: ____________________________________________________________
+92 ;;
+93 ;; 11. Retinal conditions
+94 ;;
+95 ;; a. Indicate retinal condition, and eye affected: (check all that apply)
+96 ;;
+97 ;; ___ Retinopathy ___ Right ___ Left ___ Both
+98 ;; ___ Maculopathy ___ Right ___ Left ___ Both
+99 ;; ___ Detached retina ___ Right ___ Left ___ Both
+100 ;; ___ Retinal hemorrhage ___ Right ___ Left ___ Both
+101 ;; ___ Centrally located retinal scars, atrophy or irregularities in either
+102 ;; eye that result in an irregular, duplicated, enlarged or
+103 ;; diminished image in either eye ___ Right ___ Left ___ Both
+104 ;;
+105 ;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
+106 ;; if present, attributable to any of the above checked eye conditions?
+107 ;; ___ Yes ___ No ___ There is no decrease in visual acuity or other
+108 ;; visual impairment
+109 ;; If yes, specify retinal condition responsible for visual impairment
+110 ;; ____________________________________________________________________________
+111 ;;
+112 ;; If no, explain: ____________________________________________________________
+113 ;;
+114 ;; 12. Neurologic eye conditions
+115 ;;
+116 ;; a. Indicate the Veteran's neurologic eye condition/disorder:
+117 ;; ___ Nystagmus
+118 ;; If checked, is nystagmus etiology central? ___ Yes ___ No
+119 ;; ___ Paresis/paralysis of 3rd cranial nerve (oculomotor)
+120 ;; Eye affected: ___ Right ___ Left ___ Both
+121 ;; ___ Paresis/paralysis of 4th cranial nerve (trochlear)
+122 ;; Eye affected: ___ Right ___ Left ___ Both
+123 ;; ___ Paresis/paralysis of 6th cranial nerve (abducens)
+124 ;; Eye affected: ___ Right ___ Left ___ Both
+125 ;; ___ Paresis/paralysis of 7th cranial nerve (facial, Bell's palsy)
+126 ;; Eye affected: ___ Right ___ Left ___ Both
+127 ;; ___ Eye condition due to cerebrovascular accident (CVA)
+128 ;; If checked, specify eye condition attributable to CVA: _________________
+129 ;; Eye affected: ___ Right ___ Left ___ Both
+130 ;; ___ Eye condition due to demyelinating disease
+131 ;; If checked, specify eye condition attributable to demyelinating
+132 ;; disease: _______________________________________________________________
+133 ;; Eye affected: ___ Right ___ Left ___ Both
+134 ;;^TOF^
+135 ;; ___ Optic neuritis
+136 ;; Eye affected: ___ Right ___ Left ___ Both
+137 ;; ___ Eye condition due to intracranial mass/tumor
+138 ;; If checked, specify eye condition attributable to intracranial
+139 ;; mass/tumor: ____________________________________________________________
+140 ;; Eye affected: ___ Right ___ Left ___ Both
+141 ;; ___ Eye disorder due to traumatic brain injury (TBI)
+142 ;; If checked, specify eye condition attributable to TBI: _________________
+143 ;; Eye affected: ___ Right ___ Left ___ Both
+144 ;; ___ Other
+145 ;; If checked, specify neurologic eye condition/disorder and name the
+146 ;; underlying neurologic condition (for example, Alzheimer's disease,
+147 ;; Jakob-Creutzfeldt disease, etc.): __________________________________________
+148 ;; Eye affected: ___ Right ___ Left ___ Both
+149 ;;
+150 ;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
+151 ;; if present, attributable to any of the neurologic eye conditions checked
+152 ;; above in this section?
+153 ;; ___ Yes ___ No ___ There is no decrease in visual acuity or other
+154 ;; visual impairment
+155 ;; If yes, specify condition in this section responsible for visual impairment
+156 ;; ___________________________________________________________________________.
+157 ;; If no, explain: ____________________________________________________________
+158 ;;
+159 ;; 13. Tumors and neoplasms
+160 ;;
+161 ;; Does the Veteran have a benign or malignant neoplasm or metastases related
+162 ;; to any of the diagnoses in the Diagnosis section?
+163 ;; ___ Yes ___ No
+164 ;; If yes, complete the following:
+165 ;;
+166 ;; a. Is the neoplasm:
+167 ;; ___ Benign ___ Malignant
+168 ;;
+169 ;; b. Has the Veteran completed treatment or is the Veteran currently
+170 ;; undergoing treatment for a benign or malignant neoplasm or metastases?
+171 ;; ___ Yes ___ No watchful waiting
+172 ;; If yes, indicate type of treatment the Veteran is currently undergoing
+173 ;; or has completed (check all that apply):
+174 ;; ___ Treatment completed; currently in watchful waiting status
+175 ;; ___ Surgery
+176 ;; If checked, describe: ____________________
+177 ;; Date(s) of surgery: ______________________
+178 ;; ___ Radiation therapy
+179 ;; Date of most recent treatment: ___________
+180 ;; Date of completion of treatment or anticipated date of
+181 ;; completion: ______________________________
+182 ;;^TOF^
+183 ;; ___ Antineoplastic chemotherapy
+184 ;; Date of most recent treatment: ___________
+185 ;; Date of completion of treatment or anticipated date of
+186 ;; completion:______________________________
+187 ;; ___ Other therapeutic procedure
+188 ;; If checked, describe procedure: ___________________
+189 ;; Date of most recent procedure: ____________________
+190 ;; ___ Other therapeutic treatment
+191 ;; If checked, describe treatment:
+192 ;; Date of completion of treatment or anticipated date of
+193 ;; completion:____________________
+194 ;;
+195 ;; c. Does the Veteran currently have any residual conditions or complications
+196 ;; due to the neoplasm (including metastases) or its treatment, other than
+197 ;; those already documented in the report above?
+198 ;; ___ Yes ___ No
+199 ;; If yes, list residual conditions and complications (brief summary):
+200 ;;_____________________________________________________________________________
+201 ;;
+202 ;; d. If there are additional benign or malignant neoplasms or metastases
+203 ;; related to any of the diagnoses in the Diagnosis section, describe using
+204 ;; the above format: __________________________________________________________
+205 ;;
+206 ;; e. Does any benign or malignant neoplasms or metastases identified in this
+207 ;; section cause scarring or disfigurement?
+208 ;; ___ Yes ___ No
+209 ;; If yes, complete Section IV, Scarring and disfigurement.
+210 ;;
+211 ;; 14. Other eye conditions, pertinent physical findings, complications,
+212 ;; conditions, signs and/or symptoms
+213 ;;
+214 ;; Does the Veteran have any other eye conditions, pertinent physical findings,
+215 ;; complications, conditions, signs and/or symptoms related to the condition
+216 ;; at hand?
+217 ;; ___ Yes ___ No
+218 ;; If yes, describe: __________________________________________________________
+219 ;;^TOF^
+220 ;; SECTION V: Scarring and disfigurement
+221 ;;
+222 ;; Does the Veteran have scarring or disfigurement attributable to any eye
+223 ;; condition?
+224 ;; ___ Yes ___ No
+225 ;; If yes, indicate scar attributes (check all that apply):
+226 ;; ___ Scar at least one-quarter inch (0.6 cm.) wide at widest part
+227 ;; ___ Surface contour of scar elevated or depressed on palpation (or
+228 ;; inspection in the case of cornea or sclera)
+229 ;; ___ Scar adherent to underlying tissue (including eyelids adherent to
+230 ;; scleral tissue)
+231 ;; ___ Visible or palpable tissue loss
+232 ;; ___ Gross distortion or asymmetry of one feature or paired set of
+233 ;; features (eyes)
+234 ;;
+235 ;; For all checked conditions, describe scarring and/or disfigurement:
+236 ;;_____________________________________________________________________________
+237 ;;
+238 ;; NOTE: If possible, include color photographs with any report of scarring
+239 ;; or disfigurement.
+240 ;;
+241 ;; SECTION VI: Incapacitating episodes
+242 ;;
+243 ;; During the past 12 months, has the Veteran had any incapacitating episodes
+244 ;; attributable to any eye conditions?
+245 ;; NOTE: For VA purposes, an incapacitating episode is a period of acute
+246 ;; symptoms severe enough to require prescribed bed rest and treatment by a
+247 ;; physician or other healthcare provider (For example, temporary bed rest
+248 ;; required for a retinal condition.)
+249 ;; ___ Yes ___ No
+250 ;; If yes, specify the eye condition(s) causing incapacitating episodes:
+251 ;; ____________________________________________________________________________
+252 ;;
+253 ;; Describe how the eye condition(s) caused incapacitating episodes:
+254 ;; ____________________________________________________________________________
+255 ;;
+256 ;; Provide the total duration for the incapacitating episodes for all
+257 ;; incapacitating conditions over the past 12 months:
+258 ;; ___ Less than 1 week
+259 ;; ___ At least 1 week but less than 2 weeks
+260 ;; ___ At least 2 weeks but less than 4 weeks
+261 ;; ___ At least 4 weeks but less than 6 weeks
+262 ;; ___ At least 6 weeks
+263 ;;^TOF^
+264 ;; SECTION VII
+265 ;;
+266 ;; 1. Functional impact
+267 ;;
+268 ;; Does the Veteran's eye condition(s) impact his or her ability to work?
+269 ;; ___ Yes ___ No
+270 ;; If yes, describe the impact of each of the Veteran's eye condition(s),
+271 ;; providing one or more examples: ____________________________________________
+272 ;;
+273 ;; 2. Remarks, if any: ________________________________________________________
+274 ;;
+275 ;; Optometrist/Physician signature: __________________ Date: __________________
+276 ;;
+277 ;; Optometrist/Physician printed name: ________________________________________
+278 ;;
+279 ;; Optometric/Medical license #: ______________________________________________
+280 ;;
+281 ;; State of licensure: ________________________________________________________
+282 ;;
+283 ;; Optometrist/Physician address: _____________________________________________
+284 ;;
+285 ;; Phone: ________________________ Fax: _______________________________________
+286 ;;
+287 ;; NOTE: VA may request additional medical information, including additional
+288 ;; examinations if necessary to complete VA's review of the Veteran's
+289 ;; application.
+290 ;;
+291 QUIT
