DVBCQGY2 ;;ALB-CIOFO/SBW - Gynecological Conditions Questionaire ; 7/JUL/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 she ever had a gynecological condition?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to gynecological condition(s):
;; Diagnosis #1: ____________________________
;; ICD code: ____________________________
;; Date of diagnosis: ______________________
;;
;; Diagnosis #2: ____________________________
;; ICD code: ____________________________
;; Date of diagnosis: ______________________
;;
;; Diagnosis #3: ____________________________
;; ICD code: ____________________________
;; Date of diagnosis: ______________________
;;
;; If there are additional gynecological diagnoses, list using above format:
;; _____________________________________________________________________________
;;
;; 2. Medical history
;; Describe the history (including cause, onset and course) of each of the
;; Veteran's gynecological conditions: _________________________________________
;; _____________________________________________________________________________
;;
;; 3. Symptoms
;; Does the Veteran currently have symptoms related to a gynecological
;; condition, including any diseases, injuries or adhesions of the female
;; reproductive organs?
;; ___ Yes ___ No
;; If yes, indicate current symptoms, including frequency and severity of pain,
;; if any: (check all that apply)
;; ___ Intermittent pain
;; ___ Constant pain
;; ___ Mild pain
;; ___ Moderate pain
;; ___ Severe pain
;; ___ Pelvic pressure
;; ___ Irregular menstruation
;; ___ Frequent or continuous menstrual disturbances
;; ___ Other signs and/or symptoms describe and indicate condition(s)
;; causing them: _______________________________________________________
;;^TOF^
;; 4. Treatment
;; a. Has the Veteran had treatment for symptoms/findings for any diseases,
;; injuries and/or adhesions of the reproductive organs?
;; ___ Yes ___ No
;; If yes, specify condition(s), organ(s) affected, and treatment: _________
;; _________________________________________________________________________
;; Date of treatment: ____________________
;;
;; b. Does the Veteran currently require treatment or medications [for
;; symptoms?] related to reproductive tract conditions?
;; ___ Yes ___ No
;; If yes, list current treatment/medications and the reproductive organ
;; condition(s) being treated: _________________________________________________
;;
;; c. If yes, indicate effectiveness of treatment in controlling symptoms:
;; ___ Symptoms do not require continuous treatment for the following organ/
;; condition: __________________________________________________________
;; ___ Symptoms require continuous treatment for the following organ/
;; condition: __________________________________________________________
;; ___ Symptoms are not controlled by continuous treatment: for the following
;; organ/condition: ____________________________________________________
;;
;; 5. Conditions of the vulva
;; Has the Veteran been diagnosed with any diseases, injuries or other
;; conditions of the vulva (to include vulvovaginitis)?
;; ___ Yes ___ No
;; If yes, describe: ___________________________________________________________
;;
;; 6. Conditions of the vagina
;; Has the Veteran been diagnosed with any diseases, injuries or other
;; conditions of the vagina?
;; ___ Yes ___ No
;; If yes, describe: ___________________________________________________________
;;
;; 7. Conditions of the cervix
;; Has the Veteran been diagnosed with any diseases, injuries, adhesions or
;; other conditions of the cervix?
;; ___ Yes ___ No
;; If yes, describe: ___________________________________________________________
;;
;; 8. Conditions of the uterus
;; a. Has the Veteran been diagnosed with any diseases, injuries, adhesions or
;; other conditions of the uterus?
;; ___ Yes ___ No
;;
;; b. Has the Veteran had a hysterectomy?
;; ___ Yes ___ No
;; If yes, provide date(s) of surgery, facility(ies) where performed, and cause:
;; _____________________________________________________________________________
;;^TOF^
;; c. Does the Veteran have uterine prolapse?
;; ___ Yes ___ No
;; If yes, indicate severity:
;; ___ Incomplete
;; ___ Complete (through vagina and introitus)
;; If yes, does the condition currently cause symptoms?
;; ___ Yes ___ No
;; If yes, describe: ___________________________________________________
;;
;; d. Does the Veteran have uterine fibroids, enlargement of the uterus and/or
;; displacement of the uterus?
;; ___ Yes ___ No
;; If yes, are there signs and symptoms?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Adhesions
;; ___ Marked displacement: If checked, indicate cause _____________________
;; ___ Marked enlargement: If checked, indicate cause: _____________________
;; ___ Uterine fibroids
;; ___ Irregular menstruation: If checked, indicate cause: _________________
;; ___ Frequent or continuous menstrual disturbances: If checked, indicate
;; cause: ______________________________________________________________
;; ___ Other, describe and indicate cause: _________________________________
;;
;; e. Has the Veteran been diagnosed with any other diseases, injuries,
;; adhesions or other conditions of the uterus?
;; ___ Yes ___ No
;; If yes, describe: ___________________________________________________________
;;
;; 9. Conditions of the Fallopian tubes
;; Has the Veteran been diagnosed with any diseases, injuries, adhesions or other
;; conditions of the Fallopian tubes (to include pelvic inflammatory disease)?
;; ___ Yes ___ No
;; If yes, describe: ___________________________________________________________
;;
;; 10. Conditions of the ovaries
;; a. Has the Veteran undergone menopause?
;; ___ Yes ___ No
;; If yes, indicate:
;; ___ Natural menopause
;; ___ Premature menopause
;; ___ Surgical menopause
;; ___ Chemical-induced menopause
;; ___ Radiation-induced menopause
;;^TOF^
;; b. Has the Veteran undergone partial or complete oophorectomy?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Partial removal of an ovary
;; ___ Right ___ Left ___ Both
;; ___ Complete removal of an ovary
;; ___ Right ___ Left ___ Both
;; If yes, provide date(s) of surgery, facility(ies) where performed, and reason
;; for surgery: ________________________________________________________________
;;
;; c. Does the Veteran have evidence of complete atrophy of 1 or both ovaries?
;; ___ Yes ___ No ___ Unknown
;; If yes, etiology: ______________
;; If yes, indicate severity:
;; ___ Partial atrophy of 1 or both ovaries
;; ___ Complete atrophy of 1 ovary
;; ___ Complete atrophy of both ovaries (excluding natural menopause)
;;
;; d. Has the Veteran been diagnosed with any other diseases, injuries,
;; adhesions and/or other conditions of the ovaries?
;; ___ Yes ___ No
;; If yes, describe: ___________________________________________________________
;;
;; 11. Incontinence
;; Does the Veteran have urinary incontinence/leakage?
;; ___ Yes ___ No
;; If yes, is the urinary incontinence/leakage due to a gynecologic condition?
;; ___ Yes ___ No
;; If yes, condition causing it: _______________________________________________
;; If yes, check all that apply:
;; ___ Does not require/does not use absorbent material
;; ___ Stress incontinence
;; ___ Requires absorbent material that is changed less than 2 times per day
;; ___ Requires absorbent material that is changed 2 to 4 times per day
;; ___ Requires absorbent material that is changed more than 4 times per day
;; ___ Requires the use of an appliance
;; If checked, describe appliance: ____________________________________
;;
;; 12. Fistulae
;; a. Does the Veteran have a rectovaginal fistula?
;; ___ Yes ___ No
;; If yes, cause: ______________________________________________________________
;; If yes, does the Veteran have vaginal-fecal leakage?
;; ___ Yes ___ No
;; If yes, indicate frequency (check all that apply):
;; ___ Less than once a week
;; ___ 1-3 times per week
;; ___ 4 or more times per week
;; ___ Daily or more often
;; ___ Requires wearing of pad or absorbent material
;;^TOF^
;; b. Does the Veteran have a urethrovaginal fistula?
;; ___ Yes ___ No
;; If yes, cause: ______________________________________________________________
;; If yes, does the Veteran have urine leakage?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Does not require/does not use absorbent material
;; ___ Requires absorbent material that is changed less than 2 times per day
;; ___ Requires absorbent material that is changed 2 to 4 times per day
;; ___ Requires absorbent material that is changed more than 4 times per day
;; ___ Requires the use of an appliance
;; If checked, describe appliance: ____________________________________
;;
;; 13. Endometriosis
;; Has the Veteran been diagnosed with endometriosis?
;; NOTE: A diagnosis of endometriosis must be substantiated by laparoscopy.
;; ___ Yes ___ No
;; If yes, does the Veteran currently have any findings, signs or symptoms due
;; to endometriosis?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Pelvic pain
;; ___ Heavy or irregular bleeding requiring continuous treatment for control
;; ___ Heavy or irregular bleeding not controlled by treatment
;; ___ Lesions involving bowel or bladder confirmed by laparoscopy
;; ___ Bowel or bladder symptoms from endometriosis
;; ___ Anemia caused by endometriosis
;; ___ Other, describe: ____________________________________________________
;;
;; 14. Complications and residuals of pregnancy or other gynecologic procedures
;; a. Has the Veteran had any surgical complications of pregnancy?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Relaxation of perineum
;; ___ Rectocele
;; ___ Cystocele
;; ___ Other, describe: ____________________________________________________
;;
;; b. Has the Veteran had any other complications resulting from obstetrical
;; or gynecologic conditions or procedures?
;; ___ Yes ___ No
;; If yes, describe: ___________________________________________________________
;; NOTE: If obstetrical or gynecologic complications impact other body systems,
;; also complete the additional appropriate Questionnaire(s).
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQGY2 11435 printed Oct 16, 2024@17:47:12 Page 2
DVBCQGY2 ;;ALB-CIOFO/SBW - Gynecological Conditions Questionaire ; 7/JUL/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;;
+5 ;; 1. Diagnosis
+6 ;; Does the Veteran now have or has she ever had a gynecological condition?
+7 ;; ___ Yes ___ No
+8 ;;
+9 ;; If yes, provide only diagnoses that pertain to gynecological condition(s):
+10 ;; Diagnosis #1: ____________________________
+11 ;; ICD code: ____________________________
+12 ;; Date of diagnosis: ______________________
+13 ;;
+14 ;; Diagnosis #2: ____________________________
+15 ;; ICD code: ____________________________
+16 ;; Date of diagnosis: ______________________
+17 ;;
+18 ;; Diagnosis #3: ____________________________
+19 ;; ICD code: ____________________________
+20 ;; Date of diagnosis: ______________________
+21 ;;
+22 ;; If there are additional gynecological diagnoses, list using above format:
+23 ;; _____________________________________________________________________________
+24 ;;
+25 ;; 2. Medical history
+26 ;; Describe the history (including cause, onset and course) of each of the
+27 ;; Veteran's gynecological conditions: _________________________________________
+28 ;; _____________________________________________________________________________
+29 ;;
+30 ;; 3. Symptoms
+31 ;; Does the Veteran currently have symptoms related to a gynecological
+32 ;; condition, including any diseases, injuries or adhesions of the female
+33 ;; reproductive organs?
+34 ;; ___ Yes ___ No
+35 ;; If yes, indicate current symptoms, including frequency and severity of pain,
+36 ;; if any: (check all that apply)
+37 ;; ___ Intermittent pain
+38 ;; ___ Constant pain
+39 ;; ___ Mild pain
+40 ;; ___ Moderate pain
+41 ;; ___ Severe pain
+42 ;; ___ Pelvic pressure
+43 ;; ___ Irregular menstruation
+44 ;; ___ Frequent or continuous menstrual disturbances
+45 ;; ___ Other signs and/or symptoms describe and indicate condition(s)
+46 ;; causing them: _______________________________________________________
+47 ;;^TOF^
+48 ;; 4. Treatment
+49 ;; a. Has the Veteran had treatment for symptoms/findings for any diseases,
+50 ;; injuries and/or adhesions of the reproductive organs?
+51 ;; ___ Yes ___ No
+52 ;; If yes, specify condition(s), organ(s) affected, and treatment: _________
+53 ;; _________________________________________________________________________
+54 ;; Date of treatment: ____________________
+55 ;;
+56 ;; b. Does the Veteran currently require treatment or medications [for
+57 ;; symptoms?] related to reproductive tract conditions?
+58 ;; ___ Yes ___ No
+59 ;; If yes, list current treatment/medications and the reproductive organ
+60 ;; condition(s) being treated: _________________________________________________
+61 ;;
+62 ;; c. If yes, indicate effectiveness of treatment in controlling symptoms:
+63 ;; ___ Symptoms do not require continuous treatment for the following organ/
+64 ;; condition: __________________________________________________________
+65 ;; ___ Symptoms require continuous treatment for the following organ/
+66 ;; condition: __________________________________________________________
+67 ;; ___ Symptoms are not controlled by continuous treatment: for the following
+68 ;; organ/condition: ____________________________________________________
+69 ;;
+70 ;; 5. Conditions of the vulva
+71 ;; Has the Veteran been diagnosed with any diseases, injuries or other
+72 ;; conditions of the vulva (to include vulvovaginitis)?
+73 ;; ___ Yes ___ No
+74 ;; If yes, describe: ___________________________________________________________
+75 ;;
+76 ;; 6. Conditions of the vagina
+77 ;; Has the Veteran been diagnosed with any diseases, injuries or other
+78 ;; conditions of the vagina?
+79 ;; ___ Yes ___ No
+80 ;; If yes, describe: ___________________________________________________________
+81 ;;
+82 ;; 7. Conditions of the cervix
+83 ;; Has the Veteran been diagnosed with any diseases, injuries, adhesions or
+84 ;; other conditions of the cervix?
+85 ;; ___ Yes ___ No
+86 ;; If yes, describe: ___________________________________________________________
+87 ;;
+88 ;; 8. Conditions of the uterus
+89 ;; a. Has the Veteran been diagnosed with any diseases, injuries, adhesions or
+90 ;; other conditions of the uterus?
+91 ;; ___ Yes ___ No
+92 ;;
+93 ;; b. Has the Veteran had a hysterectomy?
+94 ;; ___ Yes ___ No
+95 ;; If yes, provide date(s) of surgery, facility(ies) where performed, and cause:
+96 ;; _____________________________________________________________________________
+97 ;;^TOF^
+98 ;; c. Does the Veteran have uterine prolapse?
+99 ;; ___ Yes ___ No
+100 ;; If yes, indicate severity:
+101 ;; ___ Incomplete
+102 ;; ___ Complete (through vagina and introitus)
+103 ;; If yes, does the condition currently cause symptoms?
+104 ;; ___ Yes ___ No
+105 ;; If yes, describe: ___________________________________________________
+106 ;;
+107 ;; d. Does the Veteran have uterine fibroids, enlargement of the uterus and/or
+108 ;; displacement of the uterus?
+109 ;; ___ Yes ___ No
+110 ;; If yes, are there signs and symptoms?
+111 ;; ___ Yes ___ No
+112 ;; If yes, check all that apply:
+113 ;; ___ Adhesions
+114 ;; ___ Marked displacement: If checked, indicate cause _____________________
+115 ;; ___ Marked enlargement: If checked, indicate cause: _____________________
+116 ;; ___ Uterine fibroids
+117 ;; ___ Irregular menstruation: If checked, indicate cause: _________________
+118 ;; ___ Frequent or continuous menstrual disturbances: If checked, indicate
+119 ;; cause: ______________________________________________________________
+120 ;; ___ Other, describe and indicate cause: _________________________________
+121 ;;
+122 ;; e. Has the Veteran been diagnosed with any other diseases, injuries,
+123 ;; adhesions or other conditions of the uterus?
+124 ;; ___ Yes ___ No
+125 ;; If yes, describe: ___________________________________________________________
+126 ;;
+127 ;; 9. Conditions of the Fallopian tubes
+128 ;; Has the Veteran been diagnosed with any diseases, injuries, adhesions or other
+129 ;; conditions of the Fallopian tubes (to include pelvic inflammatory disease)?
+130 ;; ___ Yes ___ No
+131 ;; If yes, describe: ___________________________________________________________
+132 ;;
+133 ;; 10. Conditions of the ovaries
+134 ;; a. Has the Veteran undergone menopause?
+135 ;; ___ Yes ___ No
+136 ;; If yes, indicate:
+137 ;; ___ Natural menopause
+138 ;; ___ Premature menopause
+139 ;; ___ Surgical menopause
+140 ;; ___ Chemical-induced menopause
+141 ;; ___ Radiation-induced menopause
+142 ;;^TOF^
+143 ;; b. Has the Veteran undergone partial or complete oophorectomy?
+144 ;; ___ Yes ___ No
+145 ;; If yes, check all that apply:
+146 ;; ___ Partial removal of an ovary
+147 ;; ___ Right ___ Left ___ Both
+148 ;; ___ Complete removal of an ovary
+149 ;; ___ Right ___ Left ___ Both
+150 ;; If yes, provide date(s) of surgery, facility(ies) where performed, and reason
+151 ;; for surgery: ________________________________________________________________
+152 ;;
+153 ;; c. Does the Veteran have evidence of complete atrophy of 1 or both ovaries?
+154 ;; ___ Yes ___ No ___ Unknown
+155 ;; If yes, etiology: ______________
+156 ;; If yes, indicate severity:
+157 ;; ___ Partial atrophy of 1 or both ovaries
+158 ;; ___ Complete atrophy of 1 ovary
+159 ;; ___ Complete atrophy of both ovaries (excluding natural menopause)
+160 ;;
+161 ;; d. Has the Veteran been diagnosed with any other diseases, injuries,
+162 ;; adhesions and/or other conditions of the ovaries?
+163 ;; ___ Yes ___ No
+164 ;; If yes, describe: ___________________________________________________________
+165 ;;
+166 ;; 11. Incontinence
+167 ;; Does the Veteran have urinary incontinence/leakage?
+168 ;; ___ Yes ___ No
+169 ;; If yes, is the urinary incontinence/leakage due to a gynecologic condition?
+170 ;; ___ Yes ___ No
+171 ;; If yes, condition causing it: _______________________________________________
+172 ;; If yes, check all that apply:
+173 ;; ___ Does not require/does not use absorbent material
+174 ;; ___ Stress incontinence
+175 ;; ___ Requires absorbent material that is changed less than 2 times per day
+176 ;; ___ Requires absorbent material that is changed 2 to 4 times per day
+177 ;; ___ Requires absorbent material that is changed more than 4 times per day
+178 ;; ___ Requires the use of an appliance
+179 ;; If checked, describe appliance: ____________________________________
+180 ;;
+181 ;; 12. Fistulae
+182 ;; a. Does the Veteran have a rectovaginal fistula?
+183 ;; ___ Yes ___ No
+184 ;; If yes, cause: ______________________________________________________________
+185 ;; If yes, does the Veteran have vaginal-fecal leakage?
+186 ;; ___ Yes ___ No
+187 ;; If yes, indicate frequency (check all that apply):
+188 ;; ___ Less than once a week
+189 ;; ___ 1-3 times per week
+190 ;; ___ 4 or more times per week
+191 ;; ___ Daily or more often
+192 ;; ___ Requires wearing of pad or absorbent material
+193 ;;^TOF^
+194 ;; b. Does the Veteran have a urethrovaginal fistula?
+195 ;; ___ Yes ___ No
+196 ;; If yes, cause: ______________________________________________________________
+197 ;; If yes, does the Veteran have urine leakage?
+198 ;; ___ Yes ___ No
+199 ;; If yes, check all that apply:
+200 ;; ___ Does not require/does not use absorbent material
+201 ;; ___ Requires absorbent material that is changed less than 2 times per day
+202 ;; ___ Requires absorbent material that is changed 2 to 4 times per day
+203 ;; ___ Requires absorbent material that is changed more than 4 times per day
+204 ;; ___ Requires the use of an appliance
+205 ;; If checked, describe appliance: ____________________________________
+206 ;;
+207 ;; 13. Endometriosis
+208 ;; Has the Veteran been diagnosed with endometriosis?
+209 ;; NOTE: A diagnosis of endometriosis must be substantiated by laparoscopy.
+210 ;; ___ Yes ___ No
+211 ;; If yes, does the Veteran currently have any findings, signs or symptoms due
+212 ;; to endometriosis?
+213 ;; ___ Yes ___ No
+214 ;; If yes, check all that apply:
+215 ;; ___ Pelvic pain
+216 ;; ___ Heavy or irregular bleeding requiring continuous treatment for control
+217 ;; ___ Heavy or irregular bleeding not controlled by treatment
+218 ;; ___ Lesions involving bowel or bladder confirmed by laparoscopy
+219 ;; ___ Bowel or bladder symptoms from endometriosis
+220 ;; ___ Anemia caused by endometriosis
+221 ;; ___ Other, describe: ____________________________________________________
+222 ;;
+223 ;; 14. Complications and residuals of pregnancy or other gynecologic procedures
+224 ;; a. Has the Veteran had any surgical complications of pregnancy?
+225 ;; ___ Yes ___ No
+226 ;; If yes, check all that apply:
+227 ;; ___ Relaxation of perineum
+228 ;; ___ Rectocele
+229 ;; ___ Cystocele
+230 ;; ___ Other, describe: ____________________________________________________
+231 ;;
+232 ;; b. Has the Veteran had any other complications resulting from obstetrical
+233 ;; or gynecologic conditions or procedures?
+234 ;; ___ Yes ___ No
+235 ;; If yes, describe: ___________________________________________________________
+236 ;; NOTE: If obstetrical or gynecologic complications impact other body systems,
+237 ;; also complete the additional appropriate Questionnaire(s).
+238 ;;
+239 QUIT
