Home   Package List   Routine Alphabetical List   Global Alphabetical List   FileMan Files List   FileMan Sub-Files List   Package Component Lists   Package-Namespace Mapping  
Routine: DVBCQGY3

DVBCQGY3.m

Go to the documentation of this file. 
  1. DVBCQGY3 ;;ALB-CIOFO/SBW - Gynecological Conditions Questionaire (Continued); 7/JUL/2011
  1.  ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; 15. Tumors and neoplasms
  1.  ;; a. Does the Veteran have a benign or malignant neoplasm or metastases related
  1.  ;; to any of the diagnoses in the Diagnosis section?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete the following:
  1.  ;;^TOF^
  1.  ;; b. Is the neoplasm
  1.  ;; ___ Benign   ___ Malignant
  1.  ;;
  1.  ;; c. Has the Veteran completed treatment or is the Veteran currently undergoing
  1.  ;; treatment for a benign or malignant neoplasm or metastases?
  1.  ;; ___ Yes   ___ No; watchful waiting
  1.  ;; If yes, indicate type of treatment the Veteran is currently undergoing or
  1.  ;; has completed (check all that apply):
  1.  ;;     ___ Treatment completed; currently in watchful waiting status
  1.  ;;     ___ Surgery
  1.  ;;          If checked, describe: ___________________
  1.  ;;          Date(s) of surgery: __________
  1.  ;;     ___ Radiation therapy
  1.  ;;          Date of most recent treatment: ___________
  1.  ;;          Date of completion of treatment or anticipated date of completion:
  1.  ;;          _________
  1.  ;;     ___ Antineoplastic chemotherapy
  1.  ;;          Date of most recent treatment: ___________
  1.  ;;          Date of completion of treatment or anticipated date of completion:
  1.  ;;          _________
  1.  ;;     ___ Other therapeutic procedure
  1.  ;;          If checked, describe procedure: ___________________
  1.  ;;          Date of most recent procedure: __________
  1.  ;;     ___ Other therapeutic treatment
  1.  ;;          If checked, describe treatment:
  1.  ;;          Date of completion of treatment or anticipated date of completion:
  1.  ;;          _________
  1.  ;;
  1.  ;; d. Does the Veteran currently have any residual conditions or complications
  1.  ;; due to the neoplasm (including metastases) or its treatment, other than those
  1.  ;; already documented in the report above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, list residual conditions and complications (brief summary): _________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; e. If there are additional benign or malignant neoplasms or metastases
  1.  ;; related to any of the diagnoses in the Diagnosis section, describe using the
  1.  ;; above format: _______________________________________________________________
  1.  ;;
  1.  ;; 16. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  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.  ;;^TOF^
  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.  ;; 17. Diagnostic testing
  1.  ;; NOTE: If laboratory test results are in the medical record and reflect the
  1.  ;; Veteran's current condition, repeat testing is not required.
  1.  ;;
  1.  ;; a. Has the Veteran had laparoscopy?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide date(s) and facility where performed, and results: __________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; b. Has the Veteran been diagnosed with anemia?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide most recent test results:
  1.  ;;     Hgb: _____
  1.  ;;     Hct: _____
  1.  ;;     Date of test: ___________
  1.  ;;
  1.  ;; c. Has the Veteran had any other diagnostic testing and if so, are there
  1.  ;; significant findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;;  ____________________________________________________________________________
  1.  ;;
  1.  ;; 18. Functional impact
  1.  ;; Does the Veteran's gynecological condition(s) impact her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe impact of each of the Veteran's gynecological conditions,
  1.  ;; providing one or more examples: _____________________________________________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 19. Remarks, if any: ________________________________________________________
  1.  ;;
  1.  ;; Physician signature: _______________________________________  Date: _________
  1.  ;;
  1.  ;; Physician printed name: _______________________________________
  1.  ;;
  1.  ;; Medical license #: _____________
  1.  ;;
  1.  ;; Physician address: ____________________________________________ 
  1.  ;;
  1.  ;; Phone: _________________________ Fax: _________________________
  1.  ;;
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's application.
  1.  ;;^END^
  1.  Q