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Routine: DVBCQGB2

DVBCQGB2.m

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  1. DVBCQGB2 ;;ALB-CIOFO/ECF - GALLBLADDER AND PANCREAS QUESTIONNAIRE ; 6/10/2011
  1.  ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs
  1.  ;; (VA) for disability benefits.  VA will consider the information you
  1.  ;; provide on this questionnaire as part of their evaluation in processing
  1.  ;; the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;;
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with a
  1.  ;; gallbladder or pancreas condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, select the Veteran's condition (check all that apply):
  1.  ;;   ___ Chronic cholecystitis    ICD code: ______ Date of diagnosis: _________
  1.  ;;   ___ Chronic cholelithiasis   ICD code: ______ Date of diagnosis: _________
  1.  ;;   ___ Chronic cholangitis      ICD code: ______ Date of diagnosis: _________
  1.  ;;   ___ Cholecystectomy          ICD code: ______ Date of diagnosis: _________
  1.  ;;   ___ Pancreatitis             ICD code: ______ Date of diagnosis: _________
  1.  ;;   ___ Total or partial pancreatectomy
  1.  ;;                                ICD code: ______ Date of diagnosis: _________
  1.  ;;   ___ Gallbladder neoplasm     ICD code: ______ Date of diagnosis: _________
  1.  ;;   ___ Pancreatic neoplasm      ICD code: ______ Date of diagnosis: _________
  1.  ;;   ___ Gallbladder or pancreas injury, with peritoneal adhesions 
  1.  ;;       resulting from this injury
  1.  ;;                               ICD code: ______ Date of diagnosis: __________
  1.  ;;          If checked, ALSO complete the Peritoneal Adhesions Questionnaire.
  1.  ;;   ___ Other gallbladder conditions:
  1.  ;;       Other diagnosis #1: __________________
  1.  ;;       ICD code:  ___________________________
  1.  ;;       Date of diagnosis: ___________________
  1.  ;;
  1.  ;;       Other diagnosis #2: __________________
  1.  ;;       ICD code:  ___________________________
  1.  ;;       Date of diagnosis: ___________________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to gallbladder or pancreas
  1.  ;; conditions, list using above format: _______________________________________
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;;
  1.  ;; a. Describe the history (including onset and course) of the Veteran's
  1.  ;; gallbladder and/or pancreas conditions (brief summary): ____________________
  1.  ;;_____________________________________________________________________________
  1.  ;; 
  1.  ;; b. Is continuous medication required for control of the Veteran's
  1.  ;; gallbladder or pancreas conditions?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, list only those medications required for the gallbladder or pancreas
  1.  ;; condition:  ________________________________________________________________
  1.  ;;^TOF^
  1.  ;; 3. Gall bladder conditions: signs and symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have any of the following signs or symptoms attributable
  1.  ;; to any gallbladder conditions or residuals of treatment for gallbladder
  1.  ;; conditions?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Gallbladder disease-induced dyspepsia (including sphincter of Oddi
  1.  ;;        dysfunction and/or biliary dyskinesia)
  1.  ;;        If checked, indicate number of episodes per year:
  1.  ;;        ___ 0   ___ 1   ___ 2   ___ 3 ___ 4 or more
  1.  ;;    ___ Attacks of gallbladder colic
  1.  ;;        If checked, indicate number of attacks per year:
  1.  ;;        ___ 0   ___ 1   ___ 2   ___ 3 ___ 4 or more
  1.  ;;    ___ Jaundice
  1.  ;;        If checked, provide bilirubin level in Diagnostic testing section.
  1.  ;;    ___ Other signs or symptoms, describe: _________________________________
  1.  ;;
  1.  ;; 4. Pancreas conditions: signs and symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have any of the following symptoms attributable to any
  1.  ;; pancreas conditions or residuals of treatment for pancreas conditions?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Abdominal pain, confirmed as resulting from pancreatitis by
  1.  ;;        appropriate laboratory and clinical studies
  1.  ;;        If checked, indicate severity and frequency of attacks (check all
  1.  ;;        that apply):
  1.  ;;        ___ Mild (typical) ___ Moderately Severe   ___ Severe (disabling)
  1.  ;;            Indicate number of attacks of Mild (typical) abdominal pain in
  1.  ;;            the past 12 months:
  1.  ;;            ___0   __1   __2   __3   __4   __5   __6   __7  __8 or more
  1.  ;;            Indicate number of attacks of Moderately Severe abdominal pain
  1.  ;;            in the past 12 months:
  1.  ;;            ___0   __1   __2   __3   __4   __5   __6   __7  __8 or more
  1.  ;;            Indicate number of attacks of Severe (disabling) abdominal pain
  1.  ;;            in the past 12 months:
  1.  ;;            ___0   __1   __2   __3   __4   __5   __6   __7  __8 or more
  1.  ;;    ___ Remissions/pain-free intermissions between attacks
  1.  ;;        If checked, indicate characteristics of remissions:
  1.  ;;        ___ Good pain-free remissions between attacks
  1.  ;;        ___ Few pain-free intermissions between attacks
  1.  ;;        ___ Continuing pancreatic insufficiency between attacks
  1.  ;;    ___ Other symptoms, describe: ___________________________________________
  1.  ;;^TOF^
  1.  ;; b. Does the Veteran have any of the following signs or findings attributable
  1.  ;; to any pancreas conditions or residuals of treatment for pancreas
  1.  ;; conditions?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Steatorrhea
  1.  ;;        If checked, describe frequency and severity: ________________________
  1.  ;;    ___ Malabsorption
  1.  ;;        If checked, describe frequency and severity: ________________________
  1.  ;;    ___ Diarrhea
  1.  ;;        If checked, describe frequency and severity: ________________________
  1.  ;;    ___ Severe malnutrition
  1.  ;;        If checked, describe deficiency (such as beta-carotene, fat-soluble
  1.  ;;        vitamin deficiencies): ______________________________________________
  1.  ;;    ___ Weight loss
  1.  ;;        If checked, provide baseline weight: _________
  1.  ;;        and current weight: _______________
  1.  ;;        (For VA purposes, baseline weight is the average weight for 2-year
  1.  ;;        period preceding onset of disease)
  1.  ;;    ___ Other, describe: ____________________________________________________
  1.  ;;
  1.  ;; 5. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, are any of the scars painful and/or unstable, or is the total area
  1.  ;; of all related scars greater than 39 square cm (6 square inches)?
  1.  ;;    ___ Yes   ___ No
  1.  ;;        If yes, also complete a Scars Questionnaire.
  1.  ;;
  1.  ;; b. Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs and/or symptoms related to any conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): __________________________________________
  1.  ;;
  1.  ;; 6. Diagnostic testing
  1.  ;;
  1.  ;; NOTE: Diagnosis of pancreatitis must be confirmed by appropriate laboratory
  1.  ;; and clinical studies.
  1.  ;; If testing has been performed and reflects Veteran's current condition, no
  1.  ;; further testing is required for this examination report.
  1.  ;;^TOF^
  1.  ;; a. Have imaging studies been performed and are the results available?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ EUS (Endoscopic ultrasound)
  1.  ;;        Date: ___________  Results: _________________________________________
  1.  ;;    ___ ERCP (Endoscopic retrograde cholangiopancreatography)
  1.  ;;        Date: ___________  Results: _________________________________________
  1.  ;;    ___ Transhepatic cholangiogram
  1.  ;;        Date: ___________  Results: _________________________________________
  1.  ;;    ___ MRI or MRCP (magnetic resonance cholangiopancreatography)
  1.  ;;        Date: ___________  Results: _________________________________________
  1.  ;;    ___ Gallbladder scan (HIDA scan or cholescintigraphy
  1.  ;;        Date: ___________  Results: _________________________________________
  1.  ;;    ___ CT
  1.  ;;        Date: ___________  Results: _________________________________________
  1.  ;;    ___ Other, specify: _____________________________________________________
  1.  ;;        Date: ___________  Results: _________________________________________
  1.  ;;
  1.  ;; b. Has laboratory testing been performed?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Alkaline phosphatase     Date: ___________  Results: ________________
  1.  ;;    ___ Bilirubin                Date: ___________  Results: ________________
  1.  ;;    ___ WBC                      Date: ___________  Results: ________________
  1.  ;;    ___ Amylase                  Date: ___________  Results: ________________
  1.  ;;    ___ Lipase                   Date: ___________  Results: ________________
  1.  ;;    ___ Other, specify: _______  Date: ___________  Results: ________________
  1.  ;;
  1.  ;; c. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 7. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's gallbladder and/or pancreas condition(s) impact on his or
  1.  ;; her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe the impact of each of the Veteran's gallbladder and/or
  1.  ;; pancreas conditions, providing one or more examples: _______________________
  1.  ;; ____________________________________________________________________________
  1.  ;;^TOF^
  1.  ;; 8. Remarks, if any _________________________________________________________
  1.  ;;
  1.  ;; Physician signature: ____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: _________________________________ Phone: ___________
  1.  ;;
  1.  ;; Medical license #: ______________________________________ FAX: _____________
  1.  ;;
  1.  ;; Physician address: _________________________________________________________
  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.  ;;^END^
  1.  Q