DVBCQHA4 ;;ALB-CIOFO/ECF - HEMATOLOGIC INCLUDING ANEMIA QUESTIONNAIRE ; 2/15/2011
;;2.7;AMIE;**163**;Apr 10, 1995;Build 5
;
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 anemia, including anemia caused by treatment for
;; a hematologic or lymphatic condition?
;; ___ Yes ___ No (if "yes", answer both question 3.b.i and 3.b.ii)
;;
;; i. Is the anemia caused secondary to treatment of another hematologic or
;; lymphatic condition?
;; ___ Yes ___ No
;; If yes, provide the name of the other condition: ____________________
;; ii. Is continuous medication required for control of the anemia?
;; ___ Yes ___ No
;; If yes, list medication(s): _________________________________________
;;
;; c. Does the Veteran have thrombocytopenia, including thrombocytopenia
;; caused by treatment for a hematologic or lymphatic condition?
;; ___ Yes ___ No (if "yes", answer both question 3.c.i and 3.c.ii)
;;
;; i. Is the thrombocytopenia caused secondary to treatment of another
;; hematologic or lymphatic condition?
;; ___ Yes ___ No
;; If yes, provide the name of the other condition: _____________________
;; ii. Is continuous medication required for control of the thrombocytopenia?
;; ___ 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
;;^TOF^
;; 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): ___________________________________________
;;
;; 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
;;
;; a. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs and/or symptoms?
;; ___ Yes ___ No
;;
;; If yes, describe (brief summary): ___________________________________________
;;
;; b. 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, also complete a Scars Questionnaire for each scar.
;;
;; 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. CBC: _____________________________________ Date: __________________
;;
;; b. Hemoglobin level (gm/100ml):______________ Date: __________________
;;
;; c. Platelet count: __________________________ Date: __________________
;;^TOF^
;; d. 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): _______________________________________________________________
;;
;; 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 #: _______________________________________ Fax: _____________
;;
;; 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[HDVBCQHA4 11690 printed Nov 22, 2024@16:56:38 Page 2
DVBCQHA4 ;;ALB-CIOFO/ECF - HEMATOLOGIC INCLUDING ANEMIA QUESTIONNAIRE ; 2/15/2011
+1 ;;2.7;AMIE;**163**;Apr 10, 1995;Build 5
+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 ICD code: ________ Date of diagnosis: _____________
+29 ;; ___ Thrombocytopenia
+30 ;; ICD code: ________ Date of diagnosis: _____________
+31 ;; ___ Polycythemia vera
+32 ;; ICD code: ________ Date of diagnosis: _____________
+33 ;; ___ Sickle cell anemia
+34 ;; ICD code: ________ Date of diagnosis: _____________
+35 ;; ___ Splenectomy ICD code: ________ Date of diagnosis: _____________
+36 ;; ___ Hairy cell and other B-cell leukemia: If checked, complete Hairy
+37 ;; cell and other B-cell leukemias Questionnaire.
+38 ;;
+39 ;; ___ Other hematologic or lymphatic condition(s):
+40 ;; Other diagnosis #1: ___________________
+41 ;; ICD code: _____________________________
+42 ;; Date of diagnosis: ____________________
+43 ;;
+44 ;; Other diagnosis #2: ___________________
+45 ;; ICD code: _____________________________
+46 ;; Date of diagnosis: ____________________
+47 ;;^TOF^
+48 ;; Other diagnosis #3: ___________________
+49 ;; ICD code: _____________________________
+50 ;; Date of diagnosis: ____________________
+51 ;;
+52 ;; If there are additional diagnoses that pertain to hematologic or lymphatic
+53 ;; condition(s), list using above format: ______________________________________
+54 ;;
+55 ;; 2. Medical history
+56 ;;
+57 ;; a. Describe the history (including onset, course and status) of the
+58 ;; Veteran's current condition(s) (brief summary):______________________________
+59 ;;
+60 ;; _____________________________________________________________________________
+61 ;;
+62 ;; b. Indicate the status of the primary condition:
+63 ;; ___ Active
+64 ;; ___ Remission
+65 ;; ___ Not applicable
+66 ;;
+67 ;; 3. Treatment
+68 ;;
+69 ;; a. Has the Veteran completed any treatment or is the Veteran currently
+70 ;; undergoing any treatment for any lymphatic or hematologic condition,
+71 ;; including leukemia?
+72 ;; ___ Yes ___ No; watchful waiting
+73 ;;
+74 ;; If yes, indicate treatment type(s) (check all that apply):
+75 ;;
+76 ;; ___ Treatment completed; currently in watchful waiting status
+77 ;; ___ Bone marrow transplant
+78 ;; If checked, provide:
+79 ;; Date of hospital admission and location: ____________________________
+80 ;; Date of hospital discharge after transplant: _________________________
+81 ;; ___ Surgery
+82 ;; If checked, describe: ________________________________________________
+83 ;; Date(s)of surgery: _______________________
+84 ;; ___ Radiation therapy
+85 ;; Date of most recent treatment: ___________
+86 ;; Date of completion of treatment or anticipated date of completion:____
+87 ;; ___ Antineoplastic chemotherapy
+88 ;; Date of most recent treatment:____________
+89 ;; Date of completion of treatment or anticipated date of
+90 ;; completion:__________________
+91 ;; ___ Other therapeutic procedure and/or treatment (describe):______________
+92 ;; ______________________________________________________________________
+93 ;; Date of procedure:___________
+94 ;; Date of completion of treatment or anticipated date of
+95 ;; completion: _________________
+96 ;;^TOF^
+97 ;; b. Does the Veteran have anemia, including anemia caused by treatment for
+98 ;; a hematologic or lymphatic condition?
+99 ;; ___ Yes ___ No (if "yes", answer both question 3.b.i and 3.b.ii)
+100 ;;
+101 ;; i. Is the anemia caused secondary to treatment of another hematologic or
+102 ;; lymphatic condition?
+103 ;; ___ Yes ___ No
+104 ;; If yes, provide the name of the other condition: ____________________
+105 ;; ii. Is continuous medication required for control of the anemia?
+106 ;; ___ Yes ___ No
+107 ;; If yes, list medication(s): _________________________________________
+108 ;;
+109 ;; c. Does the Veteran have thrombocytopenia, including thrombocytopenia
+110 ;; caused by treatment for a hematologic or lymphatic condition?
+111 ;; ___ Yes ___ No (if "yes", answer both question 3.c.i and 3.c.ii)
+112 ;;
+113 ;; i. Is the thrombocytopenia caused secondary to treatment of another
+114 ;; hematologic or lymphatic condition?
+115 ;; ___ Yes ___ No
+116 ;; If yes, provide the name of the other condition: _____________________
+117 ;; ii. Is continuous medication required for control of the thrombocytopenia?
+118 ;; ___ Yes ___ No
+119 ;; If yes, list medication(s): __________________________________________
+120 ;;
+121 ;; 4. Conditions, complications and/or residuals
+122 ;;
+123 ;; a. Does the Veteran currently have any conditions, complications and/or
+124 ;; residuals due to a hematologic or lymphatic disorder or due to treatment
+125 ;; for a hematologic or lymphatic disorder?
+126 ;; ___ Yes ___ No
+127 ;; If yes, check all that apply:
+128 ;; ___ Weakness
+129 ;; ___ Easy fatigability
+130 ;; ___ Light-headedness
+131 ;; ___ Shortness of breath
+132 ;; ___ Headaches
+133 ;; ___ Dyspnea on mild exertion
+134 ;; ___ Dyspnea at rest
+135 ;; ___ Tachycardia
+136 ;; ___ Syncope
+137 ;; ___ Cardiomegaly
+138 ;; ___ High output congestive heart failure
+139 ;; ___ Complications or residuals of treatment requiring transfusion of
+140 ;; platelets or red blood cells
+141 ;; If checked, indicate frequency:
+142 ;; ___ At least once per year but less than once every 3 months
+143 ;; ___ At least once every 3 months
+144 ;; ___ At least once every 6 weeks
+145 ;;^TOF^
+146 ;; b. Does the Veteran currently have any other conditions, complications and/or
+147 ;; residuals of treatment from a hematologic or lymphatic disorder?
+148 ;; ___ Yes ___ No
+149 ;;
+150 ;; If yes, describe (brief summary): ___________________________________________
+151 ;;
+152 ;; 5. Recurring infections
+153 ;;
+154 ;; Does the Veteran currently have any conditions, complications and/or
+155 ;; residuals of treatment for a hematologic or lymphatic disorder that result
+156 ;; in recurring infections?
+157 ;; ___ Yes ___ No
+158 ;;
+159 ;; If yes, indicate frequency of infections:
+160 ;; ___ Less than once per year
+161 ;; ___ At least once per year but less than once every 3 months
+162 ;; ___ At least once every 3 months
+163 ;; ___ At least once every 6 weeks
+164 ;;
+165 ;; 6. Thrombocytopenia (primary, idiopathic or immune)
+166 ;;
+167 ;; Does the Veteran have thrombocytopenia?
+168 ;; ___ Yes ___ No
+169 ;;
+170 ;; If yes, check all that apply:
+171 ;; ___ Stable platelet count of 100,000 or more
+172 ;; ___ Stable platelet count between 70,000 and 100,000
+173 ;; ___ Platelet count between 20,000 and 70,000
+174 ;; ___ Platelet count of less than 20,000
+175 ;; ___ With active bleeding
+176 ;; ___ Requiring treatment with medication
+177 ;; ___ Requiring treatment with transfusions
+178 ;;
+179 ;; 7. Polycythemia vera
+180 ;;
+181 ;; Does the Veteran have polycythemia vera?
+182 ;; ___ Yes ___ No
+183 ;;
+184 ;; If yes, check all that apply:
+185 ;; ___ Stable, with or without continuous medication
+186 ;; ___ Requiring phlebotomy
+187 ;; ___ Requiring myelosuppressant treatment
+188 ;;
+189 ;; NOTE: If there are complications due to polycythemia vera such as
+190 ;; hypertension, gout, stroke or thrombotic disease, also complete appropriate
+191 ;; Questionnaire(s).
+192 ;;^TOF^
+193 ;; 8. Sickle cell anemia
+194 ;;
+195 ;; Does the Veteran have sickle cell anemia?
+196 ;; ___ Yes ___ No
+197 ;;
+198 ;; If yes, check all that apply:
+199 ;; ___ Asymptomatic
+200 ;; ___ In remission
+201 ;; ___ With identifiable organ impairment
+202 ;; ___ Following repeated hemolytic sickling crises with continuing
+203 ;; impairment of health
+204 ;; ___ Painful crises several times a year
+205 ;; ___ Repeated painful crises, occurring in skin, joints, bones or any
+206 ;; major organs
+207 ;; ___ With anemia, thrombosis and infarction
+208 ;; ___ Symptoms preclude other than light manual labor
+209 ;; ___ Symptoms preclude even light manual labor
+210 ;;
+211 ;; 9. Other pertinent physical findings, complications, conditions, signs
+212 ;; and/or symptoms
+213 ;;
+214 ;; a. Does the Veteran have any other pertinent physical findings,
+215 ;; complications, conditions, signs and/or symptoms?
+216 ;; ___ Yes ___ No
+217 ;;
+218 ;; If yes, describe (brief summary): ___________________________________________
+219 ;;
+220 ;; b. Does the Veteran have any scars (surgical or otherwise) related to any
+221 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+222 ;; section above?
+223 ;; ___ Yes ___ No
+224 ;;
+225 ;; If yes, also complete a Scars Questionnaire for each scar.
+226 ;;
+227 ;; 10. Diagnostic testing
+228 ;;
+229 ;; If testing has been performed and reflects Veteran's current condition, no
+230 ;; further testing is required.
+231 ;; Provide most recent CBC, hemoglobin level or platelet count appropriate to
+232 ;; the Veteran's condition:
+233 ;;
+234 ;; a. CBC: _____________________________________ Date: __________________
+235 ;;
+236 ;; b. Hemoglobin level (gm/100ml):______________ Date: __________________
+237 ;;
+238 ;; c. Platelet count: __________________________ Date: __________________
+239 ;;^TOF^
+240 ;; d. Are there any other significant diagnostic test findings and/or results?
+241 ;; ___ Yes ___ No
+242 ;;
+243 ;; If yes, provide type of test or procedure, date and results (brief
+244 ;; summary): _______________________________________________________________
+245 ;;
+246 ;; 11. Functional impact
+247 ;;
+248 ;; Does the Veteran's hematologic and/or lymphatic condition(s) impact his or
+249 ;; her ability to work?
+250 ;; ___ Yes ___ No
+251 ;;
+252 ;; If yes, describe impact of each of the Veteran's hematologic and/or
+253 ;; lymphatic conditions, providing one or more examples: _______________________
+254 ;;
+255 ;; 12. Remarks, if any:_________________________________________________________
+256 ;;
+257 ;; _____________________________________________________________________________
+258 ;;
+259 ;; Physician signature: _____________________________________ Date: ____________
+260 ;;
+261 ;; Physician printed name: __________________________________ Phone: ___________
+262 ;;
+263 ;; Medical license #: _______________________________________ Fax: _____________
+264 ;;
+265 ;; Physician address: __________________________________________________________
+266 ;;
+267 ;; NOTE: VA may request additional medical information, including additional
+268 ;; examinations if necessary to complete VA's review of the Veteran's
+269 ;; application.
+270 ;;
+271 ;;^END^
+272 QUIT
