DVBCQGB2 ;;ALB-CIOFO/ECF - GALLBLADDER AND PANCREAS QUESTIONNAIRE ; 6/10/2011
;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
;
TXT ;
;;
;; Your patient is applying to the U. S. Department of Veterans Affairs
;; (VA) for disability benefits. VA will consider the information you
;; provide on this questionnaire as part of their evaluation in processing
;; the Veteran's claim.
;;
;; 1. Diagnosis
;;
;; Does the Veteran now have or has he/she ever been diagnosed with a
;; gallbladder or pancreas condition?
;; ___ Yes ___ No
;;
;; If yes, select the Veteran's condition (check all that apply):
;; ___ Chronic cholecystitis ICD code: ______ Date of diagnosis: _________
;; ___ Chronic cholelithiasis ICD code: ______ Date of diagnosis: _________
;; ___ Chronic cholangitis ICD code: ______ Date of diagnosis: _________
;; ___ Cholecystectomy ICD code: ______ Date of diagnosis: _________
;; ___ Pancreatitis ICD code: ______ Date of diagnosis: _________
;; ___ Total or partial pancreatectomy
;; ICD code: ______ Date of diagnosis: _________
;; ___ Gallbladder neoplasm ICD code: ______ Date of diagnosis: _________
;; ___ Pancreatic neoplasm ICD code: ______ Date of diagnosis: _________
;; ___ Gallbladder or pancreas injury, with peritoneal adhesions
;; resulting from this injury
;; ICD code: ______ Date of diagnosis: __________
;; If checked, ALSO complete the Peritoneal Adhesions Questionnaire.
;; ___ Other gallbladder conditions:
;; Other diagnosis #1: __________________
;; ICD code: ___________________________
;; Date of diagnosis: ___________________
;;
;; Other diagnosis #2: __________________
;; ICD code: ___________________________
;; Date of diagnosis: ___________________
;;
;; If there are additional diagnoses that pertain to gallbladder or pancreas
;; conditions, list using above format: _______________________________________
;;
;; 2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's
;; gallbladder and/or pancreas conditions (brief summary): ____________________
;;_____________________________________________________________________________
;;
;; b. Is continuous medication required for control of the Veteran's
;; gallbladder or pancreas conditions?
;; ___ Yes ___ No
;; If yes, list only those medications required for the gallbladder or pancreas
;; condition: ________________________________________________________________
;;^TOF^
;; 3. Gall bladder conditions: signs and symptoms
;;
;; a. Does the Veteran have any of the following signs or symptoms attributable
;; to any gallbladder conditions or residuals of treatment for gallbladder
;; conditions?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Gallbladder disease-induced dyspepsia (including sphincter of Oddi
;; dysfunction and/or biliary dyskinesia)
;; If checked, indicate number of episodes per year:
;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 or more
;; ___ Attacks of gallbladder colic
;; If checked, indicate number of attacks per year:
;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 or more
;; ___ Jaundice
;; If checked, provide bilirubin level in Diagnostic testing section.
;; ___ Other signs or symptoms, describe: _________________________________
;;
;; 4. Pancreas conditions: signs and symptoms
;;
;; a. Does the Veteran have any of the following symptoms attributable to any
;; pancreas conditions or residuals of treatment for pancreas conditions?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Abdominal pain, confirmed as resulting from pancreatitis by
;; appropriate laboratory and clinical studies
;; If checked, indicate severity and frequency of attacks (check all
;; that apply):
;; ___ Mild (typical) ___ Moderately Severe ___ Severe (disabling)
;; Indicate number of attacks of Mild (typical) abdominal pain in
;; the past 12 months:
;; ___0 __1 __2 __3 __4 __5 __6 __7 __8 or more
;; Indicate number of attacks of Moderately Severe abdominal pain
;; in the past 12 months:
;; ___0 __1 __2 __3 __4 __5 __6 __7 __8 or more
;; Indicate number of attacks of Severe (disabling) abdominal pain
;; in the past 12 months:
;; ___0 __1 __2 __3 __4 __5 __6 __7 __8 or more
;; ___ Remissions/pain-free intermissions between attacks
;; If checked, indicate characteristics of remissions:
;; ___ Good pain-free remissions between attacks
;; ___ Few pain-free intermissions between attacks
;; ___ Continuing pancreatic insufficiency between attacks
;; ___ Other symptoms, describe: ___________________________________________
;;^TOF^
;; b. Does the Veteran have any of the following signs or findings attributable
;; to any pancreas conditions or residuals of treatment for pancreas
;; conditions?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Steatorrhea
;; If checked, describe frequency and severity: ________________________
;; ___ Malabsorption
;; If checked, describe frequency and severity: ________________________
;; ___ Diarrhea
;; If checked, describe frequency and severity: ________________________
;; ___ Severe malnutrition
;; If checked, describe deficiency (such as beta-carotene, fat-soluble
;; vitamin deficiencies): ______________________________________________
;; ___ Weight loss
;; If checked, provide baseline weight: _________
;; and current weight: _______________
;; (For VA purposes, baseline weight is the average weight for 2-year
;; period preceding onset of disease)
;; ___ Other, describe: ____________________________________________________
;;
;; 5. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;;
;; a. Does the Veteran have any scars (surgical or otherwise) related to any
;; conditions or to the treatment of any conditions listed in the Diagnosis
;; section above?
;; ___ Yes ___ No
;; If yes, are any of the scars painful and/or unstable, or is the total area
;; of all related scars greater than 39 square cm (6 square inches)?
;; ___ Yes ___ No
;; If yes, also complete a Scars Questionnaire.
;;
;; b. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs and/or symptoms related to any conditions
;; listed in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): __________________________________________
;;
;; 6. Diagnostic testing
;;
;; NOTE: Diagnosis of pancreatitis must be confirmed by appropriate laboratory
;; and clinical studies.
;; If testing has been performed and reflects Veteran's current condition, no
;; further testing is required for this examination report.
;;^TOF^
;; a. Have imaging studies been performed and are the results available?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ EUS (Endoscopic ultrasound)
;; Date: ___________ Results: _________________________________________
;; ___ ERCP (Endoscopic retrograde cholangiopancreatography)
;; Date: ___________ Results: _________________________________________
;; ___ Transhepatic cholangiogram
;; Date: ___________ Results: _________________________________________
;; ___ MRI or MRCP (magnetic resonance cholangiopancreatography)
;; Date: ___________ Results: _________________________________________
;; ___ Gallbladder scan (HIDA scan or cholescintigraphy
;; Date: ___________ Results: _________________________________________
;; ___ CT
;; Date: ___________ Results: _________________________________________
;; ___ Other, specify: _____________________________________________________
;; Date: ___________ Results: _________________________________________
;;
;; b. Has laboratory testing been performed?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Alkaline phosphatase Date: ___________ Results: ________________
;; ___ Bilirubin Date: ___________ Results: ________________
;; ___ WBC Date: ___________ Results: ________________
;; ___ Amylase Date: ___________ Results: ________________
;; ___ Lipase Date: ___________ Results: ________________
;; ___ Other, specify: _______ Date: ___________ Results: ________________
;;
;; c. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;
;; 7. Functional impact
;;
;; Does the Veteran's gallbladder and/or pancreas condition(s) impact on his or
;; her ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's gallbladder and/or
;; pancreas conditions, providing one or more examples: _______________________
;; ____________________________________________________________________________
;;^TOF^
;; 8. Remarks, if any _________________________________________________________
;;
;; Physician signature: ____________________________________ Date: ____________
;;
;; Physician printed name: _________________________________ Phone: ___________
;;
;; Medical license #: ______________________________________ FAX: _____________
;;
;; Physician address: _________________________________________________________
;;
;; NOTE: VA may request additional medical information, including additional
;; examinations if necessary to complete VA's review of the Veteran's
;; application.
;;
;;^END^
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQGB2 10339 printed Apr 09, 2024@20:58:53 Page 2
DVBCQGB2 ;;ALB-CIOFO/ECF - GALLBLADDER AND PANCREAS QUESTIONNAIRE ; 6/10/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran now have or has he/she ever been diagnosed with a
+10 ;; gallbladder or pancreas condition?
+11 ;; ___ Yes ___ No
+12 ;;
+13 ;; If yes, select the Veteran's condition (check all that apply):
+14 ;; ___ Chronic cholecystitis ICD code: ______ Date of diagnosis: _________
+15 ;; ___ Chronic cholelithiasis ICD code: ______ Date of diagnosis: _________
+16 ;; ___ Chronic cholangitis ICD code: ______ Date of diagnosis: _________
+17 ;; ___ Cholecystectomy ICD code: ______ Date of diagnosis: _________
+18 ;; ___ Pancreatitis ICD code: ______ Date of diagnosis: _________
+19 ;; ___ Total or partial pancreatectomy
+20 ;; ICD code: ______ Date of diagnosis: _________
+21 ;; ___ Gallbladder neoplasm ICD code: ______ Date of diagnosis: _________
+22 ;; ___ Pancreatic neoplasm ICD code: ______ Date of diagnosis: _________
+23 ;; ___ Gallbladder or pancreas injury, with peritoneal adhesions
+24 ;; resulting from this injury
+25 ;; ICD code: ______ Date of diagnosis: __________
+26 ;; If checked, ALSO complete the Peritoneal Adhesions Questionnaire.
+27 ;; ___ Other gallbladder conditions:
+28 ;; Other diagnosis #1: __________________
+29 ;; ICD code: ___________________________
+30 ;; Date of diagnosis: ___________________
+31 ;;
+32 ;; Other diagnosis #2: __________________
+33 ;; ICD code: ___________________________
+34 ;; Date of diagnosis: ___________________
+35 ;;
+36 ;; If there are additional diagnoses that pertain to gallbladder or pancreas
+37 ;; conditions, list using above format: _______________________________________
+38 ;;
+39 ;; 2. Medical history
+40 ;;
+41 ;; a. Describe the history (including onset and course) of the Veteran's
+42 ;; gallbladder and/or pancreas conditions (brief summary): ____________________
+43 ;;_____________________________________________________________________________
+44 ;;
+45 ;; b. Is continuous medication required for control of the Veteran's
+46 ;; gallbladder or pancreas conditions?
+47 ;; ___ Yes ___ No
+48 ;; If yes, list only those medications required for the gallbladder or pancreas
+49 ;; condition: ________________________________________________________________
+50 ;;^TOF^
+51 ;; 3. Gall bladder conditions: signs and symptoms
+52 ;;
+53 ;; a. Does the Veteran have any of the following signs or symptoms attributable
+54 ;; to any gallbladder conditions or residuals of treatment for gallbladder
+55 ;; conditions?
+56 ;; ___ Yes ___ No
+57 ;; If yes, check all that apply:
+58 ;; ___ Gallbladder disease-induced dyspepsia (including sphincter of Oddi
+59 ;; dysfunction and/or biliary dyskinesia)
+60 ;; If checked, indicate number of episodes per year:
+61 ;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 or more
+62 ;; ___ Attacks of gallbladder colic
+63 ;; If checked, indicate number of attacks per year:
+64 ;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 or more
+65 ;; ___ Jaundice
+66 ;; If checked, provide bilirubin level in Diagnostic testing section.
+67 ;; ___ Other signs or symptoms, describe: _________________________________
+68 ;;
+69 ;; 4. Pancreas conditions: signs and symptoms
+70 ;;
+71 ;; a. Does the Veteran have any of the following symptoms attributable to any
+72 ;; pancreas conditions or residuals of treatment for pancreas conditions?
+73 ;; ___ Yes ___ No
+74 ;; If yes, check all that apply:
+75 ;; ___ Abdominal pain, confirmed as resulting from pancreatitis by
+76 ;; appropriate laboratory and clinical studies
+77 ;; If checked, indicate severity and frequency of attacks (check all
+78 ;; that apply):
+79 ;; ___ Mild (typical) ___ Moderately Severe ___ Severe (disabling)
+80 ;; Indicate number of attacks of Mild (typical) abdominal pain in
+81 ;; the past 12 months:
+82 ;; ___0 __1 __2 __3 __4 __5 __6 __7 __8 or more
+83 ;; Indicate number of attacks of Moderately Severe abdominal pain
+84 ;; in the past 12 months:
+85 ;; ___0 __1 __2 __3 __4 __5 __6 __7 __8 or more
+86 ;; Indicate number of attacks of Severe (disabling) abdominal pain
+87 ;; in the past 12 months:
+88 ;; ___0 __1 __2 __3 __4 __5 __6 __7 __8 or more
+89 ;; ___ Remissions/pain-free intermissions between attacks
+90 ;; If checked, indicate characteristics of remissions:
+91 ;; ___ Good pain-free remissions between attacks
+92 ;; ___ Few pain-free intermissions between attacks
+93 ;; ___ Continuing pancreatic insufficiency between attacks
+94 ;; ___ Other symptoms, describe: ___________________________________________
+95 ;;^TOF^
+96 ;; b. Does the Veteran have any of the following signs or findings attributable
+97 ;; to any pancreas conditions or residuals of treatment for pancreas
+98 ;; conditions?
+99 ;; ___ Yes ___ No
+100 ;; If yes, check all that apply:
+101 ;; ___ Steatorrhea
+102 ;; If checked, describe frequency and severity: ________________________
+103 ;; ___ Malabsorption
+104 ;; If checked, describe frequency and severity: ________________________
+105 ;; ___ Diarrhea
+106 ;; If checked, describe frequency and severity: ________________________
+107 ;; ___ Severe malnutrition
+108 ;; If checked, describe deficiency (such as beta-carotene, fat-soluble
+109 ;; vitamin deficiencies): ______________________________________________
+110 ;; ___ Weight loss
+111 ;; If checked, provide baseline weight: _________
+112 ;; and current weight: _______________
+113 ;; (For VA purposes, baseline weight is the average weight for 2-year
+114 ;; period preceding onset of disease)
+115 ;; ___ Other, describe: ____________________________________________________
+116 ;;
+117 ;; 5. Other pertinent physical findings, complications, conditions, signs
+118 ;; and/or symptoms
+119 ;;
+120 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+121 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+122 ;; section above?
+123 ;; ___ Yes ___ No
+124 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+125 ;; of all related scars greater than 39 square cm (6 square inches)?
+126 ;; ___ Yes ___ No
+127 ;; If yes, also complete a Scars Questionnaire.
+128 ;;
+129 ;; b. Does the Veteran have any other pertinent physical findings,
+130 ;; complications, conditions, signs and/or symptoms related to any conditions
+131 ;; listed in the Diagnosis section above?
+132 ;; ___ Yes ___ No
+133 ;; If yes, describe (brief summary): __________________________________________
+134 ;;
+135 ;; 6. Diagnostic testing
+136 ;;
+137 ;; NOTE: Diagnosis of pancreatitis must be confirmed by appropriate laboratory
+138 ;; and clinical studies.
+139 ;; If testing has been performed and reflects Veteran's current condition, no
+140 ;; further testing is required for this examination report.
+141 ;;^TOF^
+142 ;; a. Have imaging studies been performed and are the results available?
+143 ;; ___ Yes ___ No
+144 ;; If yes, check all that apply:
+145 ;; ___ EUS (Endoscopic ultrasound)
+146 ;; Date: ___________ Results: _________________________________________
+147 ;; ___ ERCP (Endoscopic retrograde cholangiopancreatography)
+148 ;; Date: ___________ Results: _________________________________________
+149 ;; ___ Transhepatic cholangiogram
+150 ;; Date: ___________ Results: _________________________________________
+151 ;; ___ MRI or MRCP (magnetic resonance cholangiopancreatography)
+152 ;; Date: ___________ Results: _________________________________________
+153 ;; ___ Gallbladder scan (HIDA scan or cholescintigraphy
+154 ;; Date: ___________ Results: _________________________________________
+155 ;; ___ CT
+156 ;; Date: ___________ Results: _________________________________________
+157 ;; ___ Other, specify: _____________________________________________________
+158 ;; Date: ___________ Results: _________________________________________
+159 ;;
+160 ;; b. Has laboratory testing been performed?
+161 ;; ___ Yes ___ No
+162 ;; If yes, check all that apply:
+163 ;; ___ Alkaline phosphatase Date: ___________ Results: ________________
+164 ;; ___ Bilirubin Date: ___________ Results: ________________
+165 ;; ___ WBC Date: ___________ Results: ________________
+166 ;; ___ Amylase Date: ___________ Results: ________________
+167 ;; ___ Lipase Date: ___________ Results: ________________
+168 ;; ___ Other, specify: _______ Date: ___________ Results: ________________
+169 ;;
+170 ;; c. Are there any other significant diagnostic test findings and/or results?
+171 ;; ___ Yes ___ No
+172 ;; If yes, provide type of test or procedure, date and results (brief summary):
+173 ;; ____________________________________________________________________________
+174 ;;
+175 ;; 7. Functional impact
+176 ;;
+177 ;; Does the Veteran's gallbladder and/or pancreas condition(s) impact on his or
+178 ;; her ability to work?
+179 ;; ___ Yes ___ No
+180 ;; If yes, describe the impact of each of the Veteran's gallbladder and/or
+181 ;; pancreas conditions, providing one or more examples: _______________________
+182 ;; ____________________________________________________________________________
+183 ;;^TOF^
+184 ;; 8. Remarks, if any _________________________________________________________
+185 ;;
+186 ;; Physician signature: ____________________________________ Date: ____________
+187 ;;
+188 ;; Physician printed name: _________________________________ Phone: ___________
+189 ;;
+190 ;; Medical license #: ______________________________________ FAX: _____________
+191 ;;
+192 ;; Physician address: _________________________________________________________
+193 ;;
+194 ;; NOTE: VA may request additional medical information, including additional
+195 ;; examinations if necessary to complete VA's review of the Veteran's
+196 ;; application.
+197 ;;
+198 ;;^END^
+199 QUIT
