DVBCQHA2 ;;ALB-CIOFO/ECF - HEMATOLOGIC INCLUDING ANEMIA QUESTIONNAIRE ; 5/10/2010
;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
;
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 he/she ever been diagnosed with a hematologic
;; and/or lymphatic condition?
;; ___ Yes ___ No
;;
;; If no, provide rationale (e.g., Veteran does not currently have any known
;; hematologic or lymphatic condition(s)): _____________________________________
;;
;; If yes, select the Veteran's condition:
;;
;; ___ Acute lymphocytic leukemia (ALL)
;; ICD code: ________ Date of diagnosis: _____________
;; ___ Acute myelogenous leukemia (AML)
;; ICD code: ________ Date of diagnosis: _____________
;; ___ Chronic myelogenous leukemia (CML)
;; ICD code: ________ Date of diagnosis: _____________
;; ___ Hodgkin's disease
;; ICD code: ________ Date of diagnosis: _____________
;; ___ Non-Hodgkin's lymphoma
;; ICD code: ________ Date of diagnosis: _____________
;; ___ Anemia
;; ICD code: ________ Date of diagnosis: _____________
;; ___ Thrombocytopenia
;; ICD code: ________ Date of diagnosis: _____________
;; ___ Polycythemia vera
;; ICD code: ________ Date of diagnosis: _____________
;; ___ Sickle cell anemia
;; ICD code: ________ Date of diagnosis: _____________
;; ___ Splenectomy
;; ICD code: ________ Date of diagnosis: _____________
;; ___ Hairy cell and other B-cell leukemia: If checked, complete Hairy
;; cell and other B-cell leukemias Questionnaire.
;;
;; ___ Other hematologic or lymphatic condition(s):
;;
;; Other diagnosis #1: ___________________
;; ICD code: _____________________________
;; Date of diagnosis: ____________________
;;
;; Other diagnosis #2: ___________________
;; ICD code: _____________________________
;; Date of diagnosis: ____________________
;;^TOF^
;; Other diagnosis #3: ___________________
;; ICD code: _____________________________
;; Date of diagnosis: ____________________
;;
;; If there are additional diagnoses that pertain to hematologic or lymphatic
;; condition(s), list using above format: ______________________________________
;;
;; 2. Medical history
;;
;; a. Describe the history (including onset, course and status) of the
;; Veteran's current condition(s) (brief summary):______________________________
;;
;; _____________________________________________________________________________
;;
;; b. Indicate the status of the primary condition:
;; ___ Active
;; ___ Remission
;; ___ Not applicable
;;
;; 3. Treatment
;;
;; a. Has the Veteran completed any treatment or is the Veteran currently
;; undergoing any treatment for any lymphatic or hematologic condition,
;; including leukemia?
;; ___ Yes ___ No; watchful waiting
;;
;; If yes, indicate treatment type(s) (check all that apply):
;;
;; ___ Treatment completed; currently in watchful waiting status
;; ___ Bone marrow transplant
;; If checked, provide:
;; Date of hospital admission and location: ____________________________
;; Date of hospital discharge after transplant: _________________________
;; ___ 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 and/or treatment (describe):______________
;; Date of procedure:__________
;; Date of completion of treatment or anticipated date of completion: ___
;;^TOF^
;; b. Does the Veteran have an anemia condition, including anemia caused by
;; treatment for a hematologic or lymphatic condition?
;; ___ Yes ___ No
;;
;; If yes, is continuous medication required for control?
;; ___ Yes ___ No
;; If yes, list medication(s): _____________________________________________
;;
;; c. Does the Veteran have a thrombocytopenia condition, including
;; thrombocytopenia caused by treatment for a hematologic or lymphatic
;; condition?
;; ___ Yes ___ No
;;
;; If yes, is continuous medication required for control?
;; ___ Yes ___ No
;;
;; If yes, list medication(s): _________________________
;;
;; 4. Conditions, complications and/or residuals
;;
;; a. Does the Veteran currently have any conditions, complications and/or
;; residuals due to a hematologic or lymphatic disorder or due to treatment
;; for a hematologic or lymphatic disorder?
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ___ Weakness
;; ___ Easy fatigability
;; ___ Light-headedness
;; ___ Shortness of breath
;; ___ Headaches
;; ___ Dyspnea on mild exertion
;; ___ Dyspnea at rest
;; ___ Tachycardia
;; ___ Syncope
;; ___ Cardiomegaly
;; ___ High output congestive heart failure
;; ___ Complications or residuals of treatment requiring transfusion of
;; platelets or red blood cells
;; If checked, indicate frequency:
;; ___ At least once per year but less than once every 3 months
;; ___ At least once every 3 months
;; ___ At least once every 6 weeks
;;
;; b. Does the Veteran currently have any other conditions, complications and/or
;; residuals of treatment from a hematologic or lymphatic disorder?
;; ___ Yes ___ No
;;
;; If yes, describe (brief summary): ___________________________________________
;;^TOF^
;; 5. Recurring infections
;;
;; Does the Veteran currently have any conditions, complications and/or
;; residuals of treatment for a hematologic or lymphatic disorder that result
;; in recurring infections?
;; ___ Yes ___ No
;;
;; If yes, indicate frequency of infections:
;; ___ Less than once per year
;; ___ At least once per year but less than once every 3 months
;; ___ At least once every 3 months
;; ___ At least once every 6 weeks
;;
;; 6. Thrombocytopenia (primary, idiopathic or immune)
;;
;; Does the Veteran have thrombocytopenia?
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ___ Stable platelet count of 100,000 or more
;; ___ Stable platelet count between 70,000 and 100,000
;; ___ Platelet count between 20,000 and 70,000
;; ___ Platelet count of less than 20,000
;; ___ With active bleeding
;; ___ Requiring treatment with medication
;; ___ Requiring treatment with transfusions
;;
;; 7. Polycythemia vera
;;
;; Does the Veteran have polycythemia vera?
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ___ Stable, with or without continuous medication
;; ___ Requiring phlebotomy
;; ___ Requiring myelosuppressant treatment
;; NOTE: If there are complications due to polycythemia vera such as
;; hypertension, gout, stroke or thrombotic disease, also complete appropriate
;; Questionnaire(s).
;;^TOF^
;; 8. Sickle cell anemia
;; Does the Veteran have sickle cell anemia?
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ___ Asymptomatic
;; ___ In remission
;; ___ With identifiable organ impairment
;; ___ Following repeated hemolytic sickling crises with continuing
;; impairment of health
;; ___ Painful crises several times a year
;; ___ Repeated painful crises, occurring in skin, joints, bones or any
;; major organs
;; ___ With anemia, thrombosis and infarction
;; ___ Symptoms preclude other than light manual labor
;; ___ Symptoms preclude even light manual labor
;;
;; 9. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;;
;; Does the Veteran have any other pertinent physical findings, complications,
;; conditions, signs and/or symptoms?
;; ___ Yes ___ No
;;
;; If yes, describe (brief summary): ___________________________________________
;;
;; 10. Diagnostic testing
;;
;; If testing has been performed and reflects Veteran's current condition, no
;; further testing is required.
;; Provide most recent CBC, hemoglobin level or platelet count appropriate to
;; the Veteran's condition:
;;
;; a. Hemoglobin level (gm/100ml):_________ Date: _________________
;;
;; b. Platelet count: _____________________ Date: _________________
;;
;; c. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;;
;; If yes, provide type of test or procedure, date and results (brief
;; summary): _______________________________________________________________
;;^TOF^
;; 11. Functional impact
;; Does the Veteran's hematologic and/or lymphatic condition(s) impact his or
;; her ability to work?
;; ___ Yes ___ No
;;
;; If yes, describe impact of each of the Veteran's hematologic and/or
;; lymphatic conditions, providing one or more examples: _______________________
;;
;; 12. Remarks, if any _________________________________________________________
;;
;; _____________________________________________________________________________
;;
;; Physician signature: _____________________________________ Date: ____________
;;
;; Physician printed name: __________________________________ Phone: ___________
;;
;; Medical license #: __________________
;;
;; Physician address: __________________________________________________________
;;
;; 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[HDVBCQHA2 10469 printed Nov 22, 2024@16:56:36 Page 2
DVBCQHA2 ;;ALB-CIOFO/ECF - HEMATOLOGIC INCLUDING ANEMIA QUESTIONNAIRE ; 5/10/2010
+1 ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran now have or has he/she ever been diagnosed with a hematologic
+10 ;; and/or lymphatic condition?
+11 ;; ___ Yes ___ No
+12 ;;
+13 ;; If no, provide rationale (e.g., Veteran does not currently have any known
+14 ;; hematologic or lymphatic condition(s)): _____________________________________
+15 ;;
+16 ;; If yes, select the Veteran's condition:
+17 ;;
+18 ;; ___ Acute lymphocytic leukemia (ALL)
+19 ;; ICD code: ________ Date of diagnosis: _____________
+20 ;; ___ Acute myelogenous leukemia (AML)
+21 ;; ICD code: ________ Date of diagnosis: _____________
+22 ;; ___ Chronic myelogenous leukemia (CML)
+23 ;; ICD code: ________ Date of diagnosis: _____________
+24 ;; ___ Hodgkin's disease
+25 ;; ICD code: ________ Date of diagnosis: _____________
+26 ;; ___ Non-Hodgkin's lymphoma
+27 ;; ICD code: ________ Date of diagnosis: _____________
+28 ;; ___ Anemia
+29 ;; ICD code: ________ Date of diagnosis: _____________
+30 ;; ___ Thrombocytopenia
+31 ;; ICD code: ________ Date of diagnosis: _____________
+32 ;; ___ Polycythemia vera
+33 ;; ICD code: ________ Date of diagnosis: _____________
+34 ;; ___ Sickle cell anemia
+35 ;; ICD code: ________ Date of diagnosis: _____________
+36 ;; ___ Splenectomy
+37 ;; ICD code: ________ Date of diagnosis: _____________
+38 ;; ___ Hairy cell and other B-cell leukemia: If checked, complete Hairy
+39 ;; cell and other B-cell leukemias Questionnaire.
+40 ;;
+41 ;; ___ Other hematologic or lymphatic condition(s):
+42 ;;
+43 ;; Other diagnosis #1: ___________________
+44 ;; ICD code: _____________________________
+45 ;; Date of diagnosis: ____________________
+46 ;;
+47 ;; Other diagnosis #2: ___________________
+48 ;; ICD code: _____________________________
+49 ;; Date of diagnosis: ____________________
+50 ;;^TOF^
+51 ;; Other diagnosis #3: ___________________
+52 ;; ICD code: _____________________________
+53 ;; Date of diagnosis: ____________________
+54 ;;
+55 ;; If there are additional diagnoses that pertain to hematologic or lymphatic
+56 ;; condition(s), list using above format: ______________________________________
+57 ;;
+58 ;; 2. Medical history
+59 ;;
+60 ;; a. Describe the history (including onset, course and status) of the
+61 ;; Veteran's current condition(s) (brief summary):______________________________
+62 ;;
+63 ;; _____________________________________________________________________________
+64 ;;
+65 ;; b. Indicate the status of the primary condition:
+66 ;; ___ Active
+67 ;; ___ Remission
+68 ;; ___ Not applicable
+69 ;;
+70 ;; 3. Treatment
+71 ;;
+72 ;; a. Has the Veteran completed any treatment or is the Veteran currently
+73 ;; undergoing any treatment for any lymphatic or hematologic condition,
+74 ;; including leukemia?
+75 ;; ___ Yes ___ No; watchful waiting
+76 ;;
+77 ;; If yes, indicate treatment type(s) (check all that apply):
+78 ;;
+79 ;; ___ Treatment completed; currently in watchful waiting status
+80 ;; ___ Bone marrow transplant
+81 ;; If checked, provide:
+82 ;; Date of hospital admission and location: ____________________________
+83 ;; Date of hospital discharge after transplant: _________________________
+84 ;; ___ Surgery
+85 ;; If checked, describe: ________________________________________________
+86 ;; Date(s)of surgery: ______________
+87 ;; ___ Radiation therapy
+88 ;; Date of most recent treatment: ___________
+89 ;; Date of completion of treatment or anticipated date of completion:____
+90 ;; ___ Antineoplastic chemotherapy
+91 ;; Date of most recent treatment:___________
+92 ;; Date of completion of treatment or anticipated date of completion:____
+93 ;; ___ Other therapeutic procedure and/or treatment (describe):______________
+94 ;; Date of procedure:__________
+95 ;; Date of completion of treatment or anticipated date of completion: ___
+96 ;;^TOF^
+97 ;; b. Does the Veteran have an anemia condition, including anemia caused by
+98 ;; treatment for a hematologic or lymphatic condition?
+99 ;; ___ Yes ___ No
+100 ;;
+101 ;; If yes, is continuous medication required for control?
+102 ;; ___ Yes ___ No
+103 ;; If yes, list medication(s): _____________________________________________
+104 ;;
+105 ;; c. Does the Veteran have a thrombocytopenia condition, including
+106 ;; thrombocytopenia caused by treatment for a hematologic or lymphatic
+107 ;; condition?
+108 ;; ___ Yes ___ No
+109 ;;
+110 ;; If yes, is continuous medication required for control?
+111 ;; ___ Yes ___ No
+112 ;;
+113 ;; If yes, list medication(s): _________________________
+114 ;;
+115 ;; 4. Conditions, complications and/or residuals
+116 ;;
+117 ;; a. Does the Veteran currently have any conditions, complications and/or
+118 ;; residuals due to a hematologic or lymphatic disorder or due to treatment
+119 ;; for a hematologic or lymphatic disorder?
+120 ;; ___ Yes ___ No
+121 ;;
+122 ;; If yes, check all that apply:
+123 ;; ___ Weakness
+124 ;; ___ Easy fatigability
+125 ;; ___ Light-headedness
+126 ;; ___ Shortness of breath
+127 ;; ___ Headaches
+128 ;; ___ Dyspnea on mild exertion
+129 ;; ___ Dyspnea at rest
+130 ;; ___ Tachycardia
+131 ;; ___ Syncope
+132 ;; ___ Cardiomegaly
+133 ;; ___ High output congestive heart failure
+134 ;; ___ Complications or residuals of treatment requiring transfusion of
+135 ;; platelets or red blood cells
+136 ;; If checked, indicate frequency:
+137 ;; ___ At least once per year but less than once every 3 months
+138 ;; ___ At least once every 3 months
+139 ;; ___ At least once every 6 weeks
+140 ;;
+141 ;; b. Does the Veteran currently have any other conditions, complications and/or
+142 ;; residuals of treatment from a hematologic or lymphatic disorder?
+143 ;; ___ Yes ___ No
+144 ;;
+145 ;; If yes, describe (brief summary): ___________________________________________
+146 ;;^TOF^
+147 ;; 5. Recurring infections
+148 ;;
+149 ;; Does the Veteran currently have any conditions, complications and/or
+150 ;; residuals of treatment for a hematologic or lymphatic disorder that result
+151 ;; in recurring infections?
+152 ;; ___ Yes ___ No
+153 ;;
+154 ;; If yes, indicate frequency of infections:
+155 ;; ___ Less than once per year
+156 ;; ___ At least once per year but less than once every 3 months
+157 ;; ___ At least once every 3 months
+158 ;; ___ At least once every 6 weeks
+159 ;;
+160 ;; 6. Thrombocytopenia (primary, idiopathic or immune)
+161 ;;
+162 ;; Does the Veteran have thrombocytopenia?
+163 ;; ___ Yes ___ No
+164 ;;
+165 ;; If yes, check all that apply:
+166 ;; ___ Stable platelet count of 100,000 or more
+167 ;; ___ Stable platelet count between 70,000 and 100,000
+168 ;; ___ Platelet count between 20,000 and 70,000
+169 ;; ___ Platelet count of less than 20,000
+170 ;; ___ With active bleeding
+171 ;; ___ Requiring treatment with medication
+172 ;; ___ Requiring treatment with transfusions
+173 ;;
+174 ;; 7. Polycythemia vera
+175 ;;
+176 ;; Does the Veteran have polycythemia vera?
+177 ;; ___ Yes ___ No
+178 ;;
+179 ;; If yes, check all that apply:
+180 ;; ___ Stable, with or without continuous medication
+181 ;; ___ Requiring phlebotomy
+182 ;; ___ Requiring myelosuppressant treatment
+183 ;; NOTE: If there are complications due to polycythemia vera such as
+184 ;; hypertension, gout, stroke or thrombotic disease, also complete appropriate
+185 ;; Questionnaire(s).
+186 ;;^TOF^
+187 ;; 8. Sickle cell anemia
+188 ;; Does the Veteran have sickle cell anemia?
+189 ;; ___ Yes ___ No
+190 ;;
+191 ;; If yes, check all that apply:
+192 ;; ___ Asymptomatic
+193 ;; ___ In remission
+194 ;; ___ With identifiable organ impairment
+195 ;; ___ Following repeated hemolytic sickling crises with continuing
+196 ;; impairment of health
+197 ;; ___ Painful crises several times a year
+198 ;; ___ Repeated painful crises, occurring in skin, joints, bones or any
+199 ;; major organs
+200 ;; ___ With anemia, thrombosis and infarction
+201 ;; ___ Symptoms preclude other than light manual labor
+202 ;; ___ Symptoms preclude even light manual labor
+203 ;;
+204 ;; 9. Other pertinent physical findings, complications, conditions, signs
+205 ;; and/or symptoms
+206 ;;
+207 ;; Does the Veteran have any other pertinent physical findings, complications,
+208 ;; conditions, signs and/or symptoms?
+209 ;; ___ Yes ___ No
+210 ;;
+211 ;; If yes, describe (brief summary): ___________________________________________
+212 ;;
+213 ;; 10. Diagnostic testing
+214 ;;
+215 ;; If testing has been performed and reflects Veteran's current condition, no
+216 ;; further testing is required.
+217 ;; Provide most recent CBC, hemoglobin level or platelet count appropriate to
+218 ;; the Veteran's condition:
+219 ;;
+220 ;; a. Hemoglobin level (gm/100ml):_________ Date: _________________
+221 ;;
+222 ;; b. Platelet count: _____________________ Date: _________________
+223 ;;
+224 ;; c. Are there any other significant diagnostic test findings and/or results?
+225 ;; ___ Yes ___ No
+226 ;;
+227 ;; If yes, provide type of test or procedure, date and results (brief
+228 ;; summary): _______________________________________________________________
+229 ;;^TOF^
+230 ;; 11. Functional impact
+231 ;; Does the Veteran's hematologic and/or lymphatic condition(s) impact his or
+232 ;; her ability to work?
+233 ;; ___ Yes ___ No
+234 ;;
+235 ;; If yes, describe impact of each of the Veteran's hematologic and/or
+236 ;; lymphatic conditions, providing one or more examples: _______________________
+237 ;;
+238 ;; 12. Remarks, if any _________________________________________________________
+239 ;;
+240 ;; _____________________________________________________________________________
+241 ;;
+242 ;; Physician signature: _____________________________________ Date: ____________
+243 ;;
+244 ;; Physician printed name: __________________________________ Phone: ___________
+245 ;;
+246 ;; Medical license #: __________________
+247 ;;
+248 ;; Physician address: __________________________________________________________
+249 ;;
+250 ;; NOTE: VA may request additional medical information, including additional
+251 ;; examinations if necessary to complete VA's review of the Veteran's
+252 ;; application.
+253 ;;
+254 ;; ^END^
+255 QUIT
