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Routine: DVBCQHA2

DVBCQHA2.m

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  1. DVBCQHA2 ;;ALB-CIOFO/ECF - HEMATOLOGIC INCLUDING ANEMIA QUESTIONNAIRE ; 5/10/2010
  1.  ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs
  1.  ;; (VA) for disability benefits.  VA will consider the information you
  1.  ;; provide on this questionnaire as part of their evaluation in processing
  1.  ;; the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;;
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with a hematologic
  1.  ;; and/or lymphatic condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If no, provide rationale (e.g., Veteran does not currently have any known
  1.  ;; hematologic or lymphatic condition(s)): _____________________________________
  1.  ;;
  1.  ;; If yes, select the Veteran's condition:
  1.  ;;
  1.  ;;    ___ Acute lymphocytic leukemia (ALL)
  1.  ;;        ICD code: ________    Date of diagnosis: _____________
  1.  ;;    ___ Acute myelogenous leukemia (AML)
  1.  ;;        ICD code: ________    Date of diagnosis: _____________
  1.  ;;    ___ Chronic myelogenous leukemia (CML)
  1.  ;;        ICD code: ________    Date of diagnosis: _____________
  1.  ;;    ___ Hodgkin's disease
  1.  ;;        ICD code: ________    Date of diagnosis: _____________
  1.  ;;    ___ Non-Hodgkin's lymphoma
  1.  ;;        ICD code: ________    Date of diagnosis: _____________
  1.  ;;    ___ Anemia
  1.  ;;        ICD code: ________    Date of diagnosis: _____________
  1.  ;;    ___ Thrombocytopenia
  1.  ;;        ICD code: ________    Date of diagnosis: _____________
  1.  ;;    ___ Polycythemia vera
  1.  ;;        ICD code: ________    Date of diagnosis: _____________
  1.  ;;    ___ Sickle cell anemia
  1.  ;;        ICD code: ________    Date of diagnosis: _____________
  1.  ;;    ___ Splenectomy
  1.  ;;        ICD code: ________    Date of diagnosis: _____________
  1.  ;;    ___ Hairy cell and other B-cell leukemia: If checked, complete Hairy
  1.  ;;        cell and other B-cell leukemias Questionnaire.
  1.  ;;
  1.  ;;    ___ Other hematologic or lymphatic condition(s):  
  1.  ;;
  1.  ;;    Other diagnosis #1: ___________________
  1.  ;;    ICD code: _____________________________
  1.  ;;    Date of diagnosis: ____________________
  1.  ;;
  1.  ;;    Other diagnosis #2: ___________________
  1.  ;;    ICD code: _____________________________
  1.  ;;    Date of diagnosis: ____________________
  1.  ;;^TOF^
  1.  ;;    Other diagnosis #3: ___________________
  1.  ;;    ICD code: _____________________________
  1.  ;;    Date of diagnosis: ____________________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to hematologic or lymphatic
  1.  ;; condition(s), list using above format: ______________________________________
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;;
  1.  ;; a. Describe the history (including onset, course and status) of the
  1.  ;; Veteran's current condition(s) (brief summary):______________________________
  1.  ;;
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; b. Indicate the status of the primary condition: 
  1.  ;;    ___ Active
  1.  ;;    ___ Remission
  1.  ;;    ___ Not applicable
  1.  ;;
  1.  ;; 3. Treatment
  1.  ;;
  1.  ;; a. Has the Veteran completed any treatment or is the Veteran currently
  1.  ;; undergoing any treatment for any lymphatic or hematologic condition,
  1.  ;; including leukemia?
  1.  ;; ___ Yes   ___ No; watchful waiting
  1.  ;;
  1.  ;; If yes, indicate treatment type(s) (check all that apply):
  1.  ;;
  1.  ;;    ___ Treatment completed; currently in watchful waiting status
  1.  ;;    ___ Bone marrow transplant
  1.  ;;        If checked, provide:
  1.  ;;        Date of hospital admission and location:  ____________________________
  1.  ;;        Date of hospital discharge after transplant: _________________________
  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.  ;;    ___ Antineoplastic chemotherapy
  1.  ;;        Date of most recent treatment:___________
  1.  ;;        Date of completion of treatment or anticipated date of completion:____
  1.  ;;    ___ Other therapeutic procedure and/or treatment (describe):______________
  1.  ;;        Date of procedure:__________
  1.  ;;        Date of completion of treatment or anticipated date of completion: ___
  1.  ;;^TOF^
  1.  ;; b. Does the Veteran have an anemia condition, including anemia caused by
  1.  ;; treatment for a hematologic or lymphatic condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;;     If yes, is continuous medication required for control?
  1.  ;;     ___ Yes   ___ No
  1.  ;;     If yes, list medication(s): _____________________________________________
  1.  ;;
  1.  ;; c. Does the Veteran have a thrombocytopenia condition, including
  1.  ;; thrombocytopenia caused by treatment for a hematologic or lymphatic
  1.  ;; condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;;    If yes, is continuous medication required for control?
  1.  ;;    ___ Yes   ___ No
  1.  ;;
  1.  ;;    If yes, list medication(s): _________________________
  1.  ;;
  1.  ;; 4. Conditions, complications and/or residuals
  1.  ;;
  1.  ;; a. Does the Veteran currently have any conditions, complications and/or
  1.  ;; residuals due to a hematologic or lymphatic disorder or due to treatment
  1.  ;; for a hematologic or lymphatic disorder?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;;   If yes, check all that apply: 
  1.  ;;    ___ Weakness
  1.  ;;    ___ Easy fatigability
  1.  ;;    ___ Light-headedness
  1.  ;;    ___ Shortness of breath
  1.  ;;    ___ Headaches
  1.  ;;    ___ Dyspnea on mild exertion
  1.  ;;    ___ Dyspnea at rest
  1.  ;;    ___ Tachycardia
  1.  ;;    ___ Syncope
  1.  ;;    ___ Cardiomegaly
  1.  ;;    ___ High output congestive heart failure
  1.  ;;    ___ Complications or residuals of treatment requiring transfusion of
  1.  ;;        platelets or red blood cells
  1.  ;;           If checked, indicate frequency:
  1.  ;;           ___ At least once per year but less than once every 3 months
  1.  ;;           ___ At least once every 3 months
  1.  ;;           ___ At least once every 6 weeks
  1.  ;;
  1.  ;; b. Does the Veteran currently have any other conditions, complications and/or
  1.  ;; residuals of treatment from a hematologic or lymphatic disorder?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe (brief summary): ___________________________________________ 
  1.  ;;^TOF^
  1.  ;; 5. Recurring infections
  1.  ;;
  1.  ;; Does the Veteran currently have any conditions, complications and/or
  1.  ;; residuals of treatment for a hematologic or lymphatic disorder that result
  1.  ;; in recurring infections?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, indicate frequency of infections:
  1.  ;;    ___ Less than once per year
  1.  ;;    ___ At least once per year but less than once every 3 months
  1.  ;;    ___ At least once every 3 months
  1.  ;;    ___ At least once every 6 weeks
  1.  ;;
  1.  ;; 6. Thrombocytopenia (primary, idiopathic or immune)
  1.  ;;
  1.  ;; Does the Veteran have thrombocytopenia?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Stable platelet count of 100,000 or more
  1.  ;;    ___ Stable platelet count between 70,000 and 100,000
  1.  ;;    ___ Platelet count between 20,000 and 70,000
  1.  ;;    ___ Platelet count of less than 20,000
  1.  ;;    ___ With active bleeding
  1.  ;;    ___ Requiring treatment with medication
  1.  ;;    ___ Requiring treatment with transfusions
  1.  ;;
  1.  ;; 7. Polycythemia vera
  1.  ;;
  1.  ;; Does the Veteran have polycythemia vera?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Stable, with or without continuous medication
  1.  ;;    ___ Requiring phlebotomy
  1.  ;;    ___ Requiring myelosuppressant treatment
  1.  ;; NOTE: If there are complications due to polycythemia vera such as
  1.  ;; hypertension, gout, stroke or thrombotic disease, also complete appropriate
  1.  ;; Questionnaire(s).
  1.  ;;^TOF^
  1.  ;; 8. Sickle cell anemia
  1.  ;; Does the Veteran have sickle cell anemia?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Asymptomatic
  1.  ;;    ___ In remission
  1.  ;;    ___ With identifiable organ impairment
  1.  ;;    ___ Following repeated hemolytic sickling crises with continuing
  1.  ;;        impairment of health
  1.  ;;    ___ Painful crises several times a year
  1.  ;;    ___ Repeated painful crises, occurring in skin, joints, bones or any
  1.  ;;         major organs
  1.  ;;    ___ With anemia, thrombosis and infarction
  1.  ;;    ___ Symptoms preclude other than light manual labor 
  1.  ;;    ___ Symptoms preclude even light manual labor
  1.  ;;   
  1.  ;; 9. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;;
  1.  ;; Does the Veteran have any other pertinent physical findings, complications,
  1.  ;; conditions, signs and/or symptoms?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe (brief summary): ___________________________________________ 
  1.  ;;
  1.  ;; 10. Diagnostic testing
  1.  ;;
  1.  ;; If testing has been performed and reflects Veteran's current condition, no
  1.  ;; further testing is required.
  1.  ;; Provide most recent CBC, hemoglobin level or platelet count appropriate to
  1.  ;; the Veteran's condition:
  1.  ;; 
  1.  ;; a. Hemoglobin level (gm/100ml):_________ Date: _________________
  1.  ;;
  1.  ;; b. Platelet count: _____________________ Date: _________________
  1.  ;;
  1.  ;; c. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;;    If yes, provide type of test or procedure, date and results (brief
  1.  ;;     summary): _______________________________________________________________
  1.  ;;^TOF^
  1.  ;; 11. Functional impact 
  1.  ;; Does the Veteran's hematologic and/or lymphatic condition(s) impact his or
  1.  ;; her ability to work? 
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe impact of each of the Veteran's hematologic and/or
  1.  ;; lymphatic conditions, providing one or more examples: _______________________
  1.  ;;
  1.  ;; 12. Remarks, if any _________________________________________________________
  1.  ;;
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; Physician signature: _____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: __________________________________ Phone: ___________
  1.  ;;
  1.  ;; Medical license #: __________________
  1.  ;;
  1.  ;; Physician address: __________________________________________________________
  1.  ;; 
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's 
  1.  ;; application.
  1.  ;;                          
  1.  ;; ^END^
  1.  Q