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Routine: DVBCQEY4

DVBCQEY4.m

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  1. DVBCQEY4 ;;ALB-CIOFO/ECF -  EYE CONDITIONS QUESTIONNAIRE ; 6/15/2011
  1.  ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
  1.  ;
  1. TXT ;
  1.  ;; 7. Cataract and other lens conditions
  1.  ;;
  1.  ;; a. Indicate cataract condition:
  1.  ;; ___ Preoperative (cataract is present)
  1.  ;;     Eye affected:  ___ Right   ___ Left   ___ Both
  1.  ;; ___ Postoperative (cataract has been removed)
  1.  ;;     Eye affected:  ___ Right   ___ Left   ___ Both
  1.  ;; ___  Is there a replacement intraocular lens?
  1.  ;;      ___ Yes   ___ No
  1.  ;;      If yes, indicate eye:  ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Is there aphakia or dislocation of the crystalline lens?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate eye:  ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; c. Is the Veteran's decrease in visual acuity or other visual impairment,
  1.  ;; if 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 yes, specify condition in this section responsible for visual impairment
  1.  ;; ___________________________________________________________________________.
  1.  ;; If no, explain: ____________________________________________________________
  1.  ;;
  1.  ;; 8. Inflammatory eye conditions and/or injuries
  1.  ;;
  1.  ;; a. Indicate the Veteran's condition and eye affected:
  1.  ;; ___ Choroidopathy (including uveitis,
  1.  ;;     iritis, cyclitis, and choroiditis)  ___ Right   ___ Left   ___ Both
  1.  ;; ___ Keratopathy                         ___ Right   ___ Left   ___ Both
  1.  ;; ___ Scleritis                           ___ Right   ___ Left   ___ Both
  1.  ;; ___ Intraocular hemorrhage              ___ Right   ___ Left   ___ Both
  1.  ;; ___ Unhealed eye injury                 ___ Right   ___ Left   ___ Both
  1.  ;; ___ Other, describe: _______________________________________________________
  1.  ;;                                         ___ Right   ___ Left   ___ Both
  1.  ;;^TOF^
  1.  ;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
  1.  ;; if present, attributable to any eye condition checked above in this section?
  1.  ;; ___ Yes   ___ No  ___ There is no decrease in visual acuity or other visual
  1.  ;;                       impairment
  1.  ;; If yes, specify inflammatory or traumatic condition responsible for visual
  1.  ;; impairment ________________________________________________________________.
  1.  ;; If no, explain: ____________________________________________________________
  1.  ;;
  1.  ;; c. 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.  ;; 9. Glaucoma
  1.  ;;
  1.  ;; a. Specify the type of glaucoma:
  1.  ;; ___ Angle-closure     Eye affected:  ___ Right   ___ Left   ___ Both
  1.  ;; ___ Open-angle        Eye affected:  ___ Right   ___ Left   ___ Both
  1.  ;; ___ Other, specify type (For example, neovascular, phakolytic, etc.)
  1.  ;;     ________________________________________________________________________
  1.  ;;                       Eye affected:  ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Does the glaucoma require continuous medication for treatment?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate eye affected:  ___ Right   ___ Left   ___ Both
  1.  ;; List medication(s) used for treatment of glaucoma: _________________________
  1.  ;;
  1.  ;; c. Is the Veteran's decrease in visual acuity or other visual impairment,
  1.  ;; if present, attributable to glaucoma?
  1.  ;; ___ Yes   ___ No   ___ There is no decrease in visual acuity or other
  1.  ;;                        visual impairment
  1.  ;; If no, explain: ____________________________________________________________
  1.  ;;
  1.  ;; d. Does any glaucoma condition identified in this section cause scarring
  1.  ;; or disfigurement?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete Section IV, Scarring and disfigurement.
  1.  ;;
  1.  ;; 10. Optic neuropathy and other disc conditions
  1.  ;;
  1.  ;; a. Indicate optic neuropathy and other disc conditions, and eye affected:
  1.  ;; (check all that apply)
  1.  ;; ___ Drusen of optic disc                     ___ Right   ___ Left   ___ Both
  1.  ;; ___ Ischemic optic neuropathy                ___ Right   ___ Left   ___ Both
  1.  ;; ___ Nutritional optic neuropathy             ___ Right   ___ Left   ___ Both
  1.  ;; ___ Optic atrophy                            ___ Right   ___ Left   ___ Both
  1.  ;; ___ Other, describe _______________________  ___ Right   ___ Left   ___ Both
  1.  ;;^TOF^
  1.  ;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
  1.  ;; if present, attributable to any of the above checked eye conditions?
  1.  ;; ___ Yes   ___ No   ___ There is no decrease in visual acuity or other
  1.  ;;                        visual impairment  
  1.  ;; If yes, specify optic neuropathy or disc condition responsible for visual
  1.  ;; impairment _________________________________________________________________
  1.  ;; If no, explain: ____________________________________________________________
  1.  ;;
  1.  ;; 11. Retinal conditions
  1.  ;;
  1.  ;; a. Indicate retinal condition, and eye affected: (check all that apply)
  1.  ;;
  1.  ;; ___ Retinopathy                     ___ Right   ___ Left   ___ Both
  1.  ;; ___ Maculopathy                     ___ Right   ___ Left   ___ Both
  1.  ;; ___ Detached retina                 ___ Right   ___ Left   ___ Both
  1.  ;; ___ Retinal hemorrhage              ___ Right   ___ Left   ___ Both
  1.  ;; ___ Centrally located retinal scars, atrophy or irregularities in either
  1.  ;;     eye that result in an irregular, duplicated, enlarged or
  1.  ;;     diminished image in either eye  ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
  1.  ;; if present, attributable to any of the above checked eye conditions?
  1.  ;; ___ Yes   ___ No   ___ There is no decrease in visual acuity or other
  1.  ;;                        visual impairment
  1.  ;; If yes, specify retinal condition responsible for visual impairment
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; If no, explain: ____________________________________________________________
  1.  ;;
  1.  ;; 12. Neurologic eye conditions
  1.  ;;
  1.  ;; a. Indicate the Veteran's neurologic eye condition/disorder:
  1.  ;; ___ Nystagmus
  1.  ;;     If checked, is nystagmus etiology central? ___ Yes   ___ No
  1.  ;; ___ Paresis/paralysis of 3rd cranial nerve (oculomotor)
  1.  ;;     Eye affected:   ___ Right   ___ Left   ___ Both
  1.  ;; ___ Paresis/paralysis of 4th cranial nerve (trochlear)
  1.  ;;     Eye affected:   ___ Right   ___ Left   ___ Both
  1.  ;; ___ Paresis/paralysis of 6th cranial nerve (abducens)
  1.  ;;     Eye affected:  ___ Right   ___ Left   ___ Both
  1.  ;; ___ Paresis/paralysis of 7th cranial nerve (facial, Bell's palsy)
  1.  ;;     Eye affected:   ___ Right   ___ Left   ___ Both
  1.  ;; ___ Eye condition due to cerebrovascular accident (CVA)
  1.  ;;     If checked, specify eye condition attributable to CVA: _________________
  1.  ;;     Eye affected:  ___ Right   ___ Left   ___ Both
  1.  ;; ___ Eye condition due to demyelinating disease
  1.  ;;     If checked, specify eye condition attributable to demyelinating
  1.  ;;     disease: _______________________________________________________________
  1.  ;;     Eye affected:   ___ Right   ___ Left   ___ Both
  1.  ;;^TOF^
  1.  ;; ___ Optic neuritis
  1.  ;;     Eye affected:   ___ Right   ___ Left   ___ Both
  1.  ;; ___ Eye condition due to intracranial mass/tumor
  1.  ;;     If checked, specify eye condition attributable to intracranial
  1.  ;;     mass/tumor: ____________________________________________________________
  1.  ;;     Eye affected:   ___ Right   ___ Left   ___ Both
  1.  ;; ___ Eye disorder due to traumatic brain injury (TBI)
  1.  ;;     If checked, specify eye condition attributable to TBI: _________________
  1.  ;;     Eye affected:   ___ Right   ___ Left   ___ Both
  1.  ;; ___ Other
  1.  ;; If checked, specify neurologic eye condition/disorder and name the
  1.  ;; underlying neurologic condition (for example, Alzheimer's disease,
  1.  ;; Jakob-Creutzfeldt disease, etc.): __________________________________________
  1.  ;;     Eye affected:   ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Is the Veteran's decrease in visual acuity or other visual impairment,
  1.  ;; if present, attributable to any of the neurologic eye conditions checked
  1.  ;; above in this section?
  1.  ;; ___ Yes   ___ No   ___  There is no decrease in visual acuity or other
  1.  ;;                         visual impairment
  1.  ;; If yes, specify condition in this section responsible for visual impairment
  1.  ;; ___________________________________________________________________________.
  1.  ;; If no, explain: ____________________________________________________________
  1.  ;;
  1.  ;; 13. Tumors and neoplasms
  1.  ;;
  1.  ;; Does the Veteran have a benign or malignant neoplasm or metastases related
  1.  ;; to any of the diagnoses in the Diagnosis section?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete the following:
  1.  ;;
  1.  ;; a. Is the neoplasm:
  1.  ;; ___ Benign   ___ Malignant
  1.  ;;
  1.  ;; b. Has the Veteran completed treatment or is the Veteran currently
  1.  ;; undergoing treatment for a benign or malignant neoplasm or metastases?
  1.  ;; ___ Yes   ___ No watchful waiting
  1.  ;;    If yes, indicate type of treatment the Veteran is currently undergoing
  1.  ;;    or has completed (check all that apply):
  1.  ;;    ___ Treatment completed; currently in watchful waiting status
  1.  ;;    ___ Surgery
  1.  ;;        If checked, describe: ____________________
  1.  ;;        Date(s) of surgery: ______________________
  1.  ;;    ___ Radiation therapy
  1.  ;;        Date of most recent treatment: ___________
  1.  ;;        Date of completion of treatment or anticipated date of
  1.  ;;        completion: ______________________________
  1.  ;;^TOF^
  1.  ;;    ___ Antineoplastic chemotherapy
  1.  ;;        Date of most recent treatment: ___________
  1.  ;;        Date of completion of treatment or anticipated date of
  1.  ;;        completion:______________________________
  1.  ;;    ___ Other therapeutic procedure
  1.  ;;        If checked, describe procedure: ___________________
  1.  ;;        Date of most recent procedure: ____________________
  1.  ;;    ___ Other therapeutic treatment
  1.  ;;        If checked, describe treatment:
  1.  ;;        Date of completion of treatment or anticipated date of
  1.  ;;        completion:____________________
  1.  ;;
  1.  ;; c. Does the Veteran currently have any residual conditions or complications
  1.  ;; due to the neoplasm (including metastases) or its treatment, other than
  1.  ;; those already documented in the report above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, list residual conditions and complications (brief summary):
  1.  ;;_____________________________________________________________________________
  1.  ;;
  1.  ;; d. If there are additional benign or malignant neoplasms or metastases
  1.  ;; related to any of the diagnoses in the Diagnosis section, describe using
  1.  ;; the above format: __________________________________________________________
  1.  ;;
  1.  ;; e. Does any benign or malignant neoplasms or metastases identified in this
  1.  ;; section cause scarring or disfigurement?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete Section IV, Scarring and disfigurement.
  1.  ;;
  1.  ;; 14. Other eye conditions, pertinent physical findings, complications,
  1.  ;; conditions, signs and/or symptoms
  1.  ;;
  1.  ;; Does the Veteran have any other eye conditions, pertinent physical findings,
  1.  ;; complications, conditions, signs and/or symptoms related to the condition
  1.  ;; at hand?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe: __________________________________________________________
  1.  ;;^TOF^
  1.  ;; SECTION V: Scarring and disfigurement
  1.  ;;
  1.  ;; Does the Veteran have scarring or disfigurement attributable to any eye
  1.  ;; condition?
  1.  ;; ___ Yes   ___ No 
  1.  ;; If yes, indicate scar attributes (check all that apply):
  1.  ;;    ___ Scar at least one-quarter inch (0.6 cm.) wide at widest part
  1.  ;;    ___ Surface contour of scar elevated or depressed on palpation (or
  1.  ;;        inspection in the case of cornea or sclera)
  1.  ;;    ___ Scar adherent to underlying tissue (including eyelids adherent to
  1.  ;;        scleral tissue)
  1.  ;;    ___ Visible or palpable tissue loss
  1.  ;;    ___ Gross distortion or asymmetry of one feature or paired set of
  1.  ;;        features (eyes)
  1.  ;;
  1.  ;; For all checked conditions, describe scarring and/or disfigurement:
  1.  ;;_____________________________________________________________________________
  1.  ;;
  1.  ;; NOTE: If possible, include color photographs with any report of scarring
  1.  ;; or disfigurement.
  1.  ;;
  1.  ;; SECTION VI: Incapacitating episodes
  1.  ;;
  1.  ;; During the past 12 months, has the Veteran had any incapacitating episodes
  1.  ;; attributable to any eye conditions?
  1.  ;; NOTE: For VA purposes, an incapacitating episode is a period of acute
  1.  ;; symptoms severe enough to require prescribed bed rest and treatment by a
  1.  ;; physician or other healthcare provider (For example, temporary bed rest
  1.  ;; required for a retinal condition.)
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, specify the eye condition(s) causing incapacitating episodes:
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; Describe how the eye condition(s) caused incapacitating episodes:
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; Provide the total duration for the incapacitating episodes for all
  1.  ;; incapacitating conditions over the past 12 months:
  1.  ;; ___ Less than 1 week
  1.  ;; ___ At least 1 week but less than 2 weeks
  1.  ;; ___ At least 2 weeks but less than 4 weeks
  1.  ;; ___ At least 4 weeks but less than 6 weeks
  1.  ;; ___ At least 6 weeks
  1.  ;;^TOF^
  1.  ;; SECTION VII
  1.  ;;
  1.  ;; 1. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's eye condition(s) impact his or her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe the impact of each of the Veteran's eye condition(s),
  1.  ;; providing one or more examples: ____________________________________________
  1.  ;;
  1.  ;; 2. Remarks, if any: ________________________________________________________
  1.  ;;
  1.  ;; Optometrist/Physician signature: __________________ Date: __________________
  1.  ;;
  1.  ;; Optometrist/Physician printed name: ________________________________________
  1.  ;;
  1.  ;; Optometric/Medical license #: ______________________________________________
  1.  ;;
  1.  ;; State of licensure: ________________________________________________________
  1.  ;;
  1.  ;; Optometrist/Physician address: _____________________________________________
  1.  ;;
  1.  ;; Phone: ________________________ Fax: _______________________________________
  1.  ;;
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's
  1.  ;; application.
  1.  ;;
  1.  Q