DVBCQGY3 ;;ALB-CIOFO/SBW - Gynecological Conditions Questionaire (Continued); 7/JUL/2011
;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
;
TXT ;
;; 15. Tumors and neoplasms
;; a. Does the Veteran have a benign or malignant neoplasm or metastases related
;; to any of the diagnoses in the Diagnosis section?
;; ___ Yes ___ No
;; If yes, complete the following:
;;^TOF^
;; b. Is the neoplasm
;; ___ Benign ___ Malignant
;;
;; c. Has the Veteran completed treatment or is the Veteran currently undergoing
;; treatment for a benign or malignant neoplasm or metastases?
;; ___ Yes ___ No; watchful waiting
;; If yes, indicate type of treatment the Veteran is currently undergoing or
;; has completed (check all that apply):
;; ___ Treatment completed; currently in watchful waiting status
;; ___ Surgery
;; If checked, describe: ___________________
;; Date(s) of surgery: __________
;; ___ Radiation therapy
;; Date of most recent treatment: ___________
;; Date of completion of treatment or anticipated date of completion:
;; _________
;; ___ Antineoplastic chemotherapy
;; Date of most recent treatment: ___________
;; Date of completion of treatment or anticipated date of completion:
;; _________
;; ___ Other therapeutic procedure
;; If checked, describe procedure: ___________________
;; Date of most recent procedure: __________
;; ___ Other therapeutic treatment
;; If checked, describe treatment:
;; Date of completion of treatment or anticipated date of completion:
;; _________
;;
;; d. Does the Veteran currently have any residual conditions or complications
;; due to the neoplasm (including metastases) or its treatment, other than those
;; already documented in the report above?
;; ___ Yes ___ No
;; If yes, list residual conditions and complications (brief summary): _________
;; _____________________________________________________________________________
;;
;; e. If there are additional benign or malignant neoplasms or metastases
;; related to any of the diagnoses in the Diagnosis section, describe using the
;; above format: _______________________________________________________________
;;
;; 16. 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.
;;^TOF^
;; 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): ___________________________________________
;;
;; 17. Diagnostic testing
;; NOTE: If laboratory test results are in the medical record and reflect the
;; Veteran's current condition, repeat testing is not required.
;;
;; a. Has the Veteran had laparoscopy?
;; ___ Yes ___ No
;; If yes, provide date(s) and facility where performed, and results: __________
;; _____________________________________________________________________________
;;
;; b. Has the Veteran been diagnosed with anemia?
;; ___ Yes ___ No
;; If yes, provide most recent test results:
;; Hgb: _____
;; Hct: _____
;; Date of test: ___________
;;
;; c. Has the Veteran had any other diagnostic testing and if so, are there
;; significant findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;
;; 18. Functional impact
;; Does the Veteran's gynecological condition(s) impact her ability to work?
;; ___ Yes ___ No
;; If yes, describe impact of each of the Veteran's gynecological conditions,
;; providing one or more examples: _____________________________________________
;; _____________________________________________________________________________
;;
;; 19. Remarks, if any: ________________________________________________________
;;
;; Physician signature: _______________________________________ Date: _________
;;
;; Physician printed name: _______________________________________
;;
;; Medical license #: _____________
;;
;; Physician address: ____________________________________________
;;
;; Phone: _________________________ Fax: _________________________
;;
;; 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[HDVBCQGY3 5120 printed Apr 09, 2024@20:56:29 Page 2
DVBCQGY3 ;;ALB-CIOFO/SBW - Gynecological Conditions Questionaire (Continued); 7/JUL/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; 15. Tumors and neoplasms
+2 ;; a. Does the Veteran have a benign or malignant neoplasm or metastases related
+3 ;; to any of the diagnoses in the Diagnosis section?
+4 ;; ___ Yes ___ No
+5 ;; If yes, complete the following:
+6 ;;^TOF^
+7 ;; b. Is the neoplasm
+8 ;; ___ Benign ___ Malignant
+9 ;;
+10 ;; c. Has the Veteran completed treatment or is the Veteran currently undergoing
+11 ;; treatment for a benign or malignant neoplasm or metastases?
+12 ;; ___ Yes ___ No; watchful waiting
+13 ;; If yes, indicate type of treatment the Veteran is currently undergoing or
+14 ;; has completed (check all that apply):
+15 ;; ___ Treatment completed; currently in watchful waiting status
+16 ;; ___ Surgery
+17 ;; If checked, describe: ___________________
+18 ;; Date(s) of surgery: __________
+19 ;; ___ Radiation therapy
+20 ;; Date of most recent treatment: ___________
+21 ;; Date of completion of treatment or anticipated date of completion:
+22 ;; _________
+23 ;; ___ Antineoplastic chemotherapy
+24 ;; Date of most recent treatment: ___________
+25 ;; Date of completion of treatment or anticipated date of completion:
+26 ;; _________
+27 ;; ___ Other therapeutic procedure
+28 ;; If checked, describe procedure: ___________________
+29 ;; Date of most recent procedure: __________
+30 ;; ___ Other therapeutic treatment
+31 ;; If checked, describe treatment:
+32 ;; Date of completion of treatment or anticipated date of completion:
+33 ;; _________
+34 ;;
+35 ;; d. Does the Veteran currently have any residual conditions or complications
+36 ;; due to the neoplasm (including metastases) or its treatment, other than those
+37 ;; already documented in the report above?
+38 ;; ___ Yes ___ No
+39 ;; If yes, list residual conditions and complications (brief summary): _________
+40 ;; _____________________________________________________________________________
+41 ;;
+42 ;; e. If there are additional benign or malignant neoplasms or metastases
+43 ;; related to any of the diagnoses in the Diagnosis section, describe using the
+44 ;; above format: _______________________________________________________________
+45 ;;
+46 ;; 16. Other pertinent physical findings, complications, conditions, signs
+47 ;; and/or symptoms
+48 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+49 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+50 ;; section above?
+51 ;; ___ Yes ___ No
+52 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+53 ;; of all related scars greater than 39 square cm (6 square inches)?
+54 ;; ___ Yes ___ No
+55 ;; If yes, also complete a Scars Questionnaire.
+56 ;;^TOF^
+57 ;; b. Does the Veteran have any other pertinent physical findings,
+58 ;; complications, conditions, signs and/or symptoms related to any conditions
+59 ;; listed in the Diagnosis section above?
+60 ;; ___ Yes ___ No
+61 ;; If yes, describe (brief summary): ___________________________________________
+62 ;;
+63 ;; 17. Diagnostic testing
+64 ;; NOTE: If laboratory test results are in the medical record and reflect the
+65 ;; Veteran's current condition, repeat testing is not required.
+66 ;;
+67 ;; a. Has the Veteran had laparoscopy?
+68 ;; ___ Yes ___ No
+69 ;; If yes, provide date(s) and facility where performed, and results: __________
+70 ;; _____________________________________________________________________________
+71 ;;
+72 ;; b. Has the Veteran been diagnosed with anemia?
+73 ;; ___ Yes ___ No
+74 ;; If yes, provide most recent test results:
+75 ;; Hgb: _____
+76 ;; Hct: _____
+77 ;; Date of test: ___________
+78 ;;
+79 ;; c. Has the Veteran had any other diagnostic testing and if so, are there
+80 ;; significant findings and/or results?
+81 ;; ___ Yes ___ No
+82 ;; If yes, provide type of test or procedure, date and results (brief summary):
+83 ;; ____________________________________________________________________________
+84 ;;
+85 ;; 18. Functional impact
+86 ;; Does the Veteran's gynecological condition(s) impact her ability to work?
+87 ;; ___ Yes ___ No
+88 ;; If yes, describe impact of each of the Veteran's gynecological conditions,
+89 ;; providing one or more examples: _____________________________________________
+90 ;; _____________________________________________________________________________
+91 ;;
+92 ;; 19. Remarks, if any: ________________________________________________________
+93 ;;
+94 ;; Physician signature: _______________________________________ Date: _________
+95 ;;
+96 ;; Physician printed name: _______________________________________
+97 ;;
+98 ;; Medical license #: _____________
+99 ;;
+100 ;; Physician address: ____________________________________________
+101 ;;
+102 ;; Phone: _________________________ Fax: _________________________
+103 ;;
+104 ;; NOTE: VA may request additional medical information, including additional
+105 ;; examinations if necessary to complete VA's review of the Veteran's application.
+106 ;;^END^
+107 QUIT
