Routine: DVBCQGY2

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).

;;

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQGY2   11435     printed  Apr 23, 2025@18:00:51                                                                                                                                                                                                   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

DVBCQGY2.m