Routine: DVBCQHA6

DVBCQHA6 ;;ALB-CIOFO/ECF,SBW - HEMATOLOGIC INCLUDING ANEMIA QUESTIONNAIRE (V3) ; 14/APR/2011

 ;;2.7;AMIE;**166**;Apr 10, 1995;Build 6

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

 ;; or lymphatic condition?

 ;; ___ Yes   ___ No

;;

 ;; If yes, select the Veteran's condition(s) (check all that apply):

 ;;    ___ 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: ____________

 ;;    ___ Chronic lymphocytic leukemia (CLL)

 ;;                           ICD code: ________  Date of diagnosis: ____________

 ;;    ___ Hodgkin's disease  ICD code: ________  Date of diagnosis: ____________

 ;;    ___ Non-Hodgkin's lymphoma

 ;;                           ICD code: ________  Date of diagnosis: ____________

 ;;    ___ Multiple myeloma   ICD code: ________  Date of diagnosis: ____________

 ;;    ___ Myelodysplastic syndrome

 ;;                           ICD code: ________  Date of diagnosis: ____________

 ;;    ___ Plasmacytoma       ICD code: ________  Date of diagnosis: ____________

 ;;    ___ Anemia (such as anemia of chronic disease, aplastic anemia, hemolytic

 ;;        anemia, iron or vitamin-deficient anemias, thalassemias, myelophthisic

 ;;        anemia, etc.)      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 or other B-cell leukemia: If checked, complete Hairy cell

 ;;        and other B-cell leukemias Questionnaire in lieu of this Questionnaire.

 ;;    ___ Other, specify:

 ;;           Other diagnosis #1: ___________________

 ;;           ICD code: _____________________________

 ;;           Date of diagnosis: ____________________

;;

 ;;           Other diagnosis #2: ___________________

 ;;           ICD code: _____________________________

 ;;           Date of diagnosis: ____________________

;;

 ;;           Other diagnosis #3: ___________________

 ;;           ICD code: _____________________________

 ;;           Date of diagnosis: ____________________

;;

 ;; If there are additional diagnoses that pertain to hematologic or lymphatic

 ;; conditions, list using above format: ________________________________________

 ;;^TOF^

 ;; 2. Medical history

 ;; a. Describe the history (including onset and course) of the Veteran's

 ;; hematologic or lymphatic condition (brief summary):__________________________

;;

 ;; b. Is continuous medication required for control of a hematologic or lymphatic

 ;; condition, including anemia or thrombocytopenia caused by treatment for a

 ;; hematologic or lymphatic condition?

 ;; ___ Yes   ___ No

 ;; If yes, list only those medications required for control of the Veteran's

 ;; hematologic or lymphatic condition, including anemia or thrombocytopenia

 ;; caused by treatment for a hematologic or lymphatic condition. Provide the

 ;; name of the medication and the condition the medication is used to treat:

 ;; _____________________________________________________________________________

;;

 ;; c. Indicate the status of the primary hematologic or lymphatic condition:

 ;;     ___ Active

 ;;     ___ Remission

 ;;     ___ Not applicable

;;

 ;; 3. Treatment

 ;; a. Has the Veteran completed any treatment or is the Veteran currently

 ;; undergoing any treatment for any hematologic or lymphatic condition,

 ;; including leukemia?

 ;; ___ 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

 ;;    ___ 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

 ;;              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: ____________________________________________________

 ;;^TOF^

 ;; 4. Anemia and thrombocytopenia (primary, secondary, idiopathic and immune)

 ;; Does the Veteran have anemia or thrombocytopenia, including that caused by

 ;; treatment for a hematologic or lymphatic condition?

 ;; ___ Yes   ___ No

 ;; If yes, complete the following:

;;

 ;; a. Does the Veteran have anemia?

 ;; ___ Yes   ___ No

 ;; If yes, is the anemia caused by treatment for another hematologic or lymphatic

 ;; condition?

 ;; ___ Yes   ___ No

 ;; If yes, provide the name of the other hematologic or lymphatic condition

 ;; causing the secondary anemia: _______________________________________________

;;

 ;; b. Does the Veteran have thrombocytopenia?

 ;; ___ Yes   ___ No

 ;; If yes, is the thrombocytopenia caused by treatment for another hematologic

 ;; or lymphatic condition?

 ;; ___ Yes   ___ No

 ;; If yes, provide the name of the other hematologic or lymphatic condition

 ;; causing the secondary thrombocytopenia: _____________________________________

;;

 ;; If the Veteran has thrombocytopenia, select the answer that best represents

 ;; the Veteran's condition:

 ;;    ___ 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

 ;;    ___ Other, describe: _____________________________________________________

;;

 ;; c. Does the Veteran have any complications or residuals of treatment requiring

 ;; transfusion of platelets or red blood cells?

 ;; ___ Yes   ___ No

 ;; If yes, indicate frequency of transfusions in the past 12 months:

 ;;    ___ None

 ;;    ___ 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^

 ;; 5. Findings, signs and symptoms

 ;; Does the Veteran currently have any findings, signs and symptoms due to a

 ;; hematologic or lymphatic disorder or to treatment for a hematologic or

 ;; lymphatic disorder?

 ;; ___ Yes   ___ No

 ;; If yes, check all that apply:

 ;;    ___ Weakness

 ;;      If checked, describe: __________________________________________________

 ;;    ___ Easy fatigability

 ;;      If checked, describe: __________________________________________________

 ;;    ___ Light-headedness

 ;;      If checked, describe: __________________________________________________

 ;;    ___ Shortness of breath

 ;;      If checked, describe: __________________________________________________

 ;;    ___ Headaches

 ;;      If checked, describe: __________________________________________________

 ;;    ___ Dyspnea on mild exertion

 ;;      If checked, describe: __________________________________________________

 ;;    ___ Dyspnea at rest

 ;;      If checked, describe: __________________________________________________

 ;;    ___ Tachycardia

 ;;      If checked, describe: __________________________________________________

 ;;    ___ Syncope

 ;;      If checked, describe: __________________________________________________

 ;;    ___ Cardiomegaly

 ;;    ___ High output congestive heart failure

 ;;    ___ Other, describe: _____________________________________________________

;;

 ;; 6. Recurring infections

 ;; Does the Veteran currently have recurring infections attributable to any

 ;; conditions, complications or residuals of treatment for a hematologic or

 ;; lymphatic disorder?

 ;; ___ Yes   ___ No

 ;; If yes, indicate frequency of infections over past 12 months:

 ;;    ___ None

 ;;    ___ At least once per year but less than once every 3 months

 ;;    ___ At least once every 3 months

 ;;    ___ At least once every 6 weeks

;;

 ;; 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

 ;;    ___ Other, describe: _____________________________________________________

;;

 ;; NOTE: If there are complications due to polycythemia vera such as hypertension,

 ;; gout, stroke or thrombotic disease, ALSO complete appropriate Questionnaire

 ;; for each condition.

;;

 ;; 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

 ;;    ___ Other, describe: _____________________________________________________

;;

 ;; 9. 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.

;;

 ;; b. 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.

 ;; When appropriate, provide most recent complete blood count.

;;

 ;; a. Has laboratory testing been performed?

 ;; ___ Yes   ___ No

 ;; If yes, provide results:

 ;;    Hemoglobin (gm/100ml): __________________________  Date: _________________

 ;;    Hematocrit: _____________________________________  Date: _________________

 ;;    Red blood cell (RBC) count: _____________________  Date: _________________

 ;;    White blood cell (WBC) count: ___________________  Date: _________________

 ;;    White blood cell differential count: ____________  Date: _________________

 ;;    Platelet count: _________________________________  Date: _________________

;;

 ;; b. 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

;;

 ;; Do the Veteran's hematologic 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 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^

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQHA6   13931     printed  Mar 13, 2025@20:51:10                                                                                                                                                                                                   Page 2

DVBCQHA6  ;;ALB-CIOFO/ECF,SBW - HEMATOLOGIC INCLUDING ANEMIA QUESTIONNAIRE (V3) ; 14/APR/2011

 +1       ;;2.7;AMIE;**166**;Apr 10, 1995;Build 6

 +2       ;

TXT       ;

 +1       ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for

 +2       ;; disability benefits.  VA will consider the information you provide on this

 +3       ;; questionnaire as part of their evaluation in processing the Veteran's claim.

 +4       ;;

 +5       ;; 1. Diagnosis

 +6       ;; Does the Veteran now have or has he/she ever been diagnosed with a hematologic

 +7       ;; or lymphatic condition?

 +8       ;; ___ Yes   ___ No

 +9       ;;

 +10      ;; If yes, select the Veteran's condition(s) (check all that apply):

 +11      ;;    ___ Acute lymphocytic leukemia (ALL)

 +12      ;;                           ICD code: ________  Date of diagnosis: ____________

 +13      ;;    ___ Acute myelogenous leukemia (AML)

 +14      ;;                           ICD code: ________  Date of diagnosis: ____________

 +15      ;;    ___ Chronic myelogenous leukemia (CML)

 +16      ;;                           ICD code: ________  Date of diagnosis: ____________

 +17      ;;    ___ Chronic lymphocytic leukemia (CLL)

 +18      ;;                           ICD code: ________  Date of diagnosis: ____________

 +19      ;;    ___ Hodgkin's disease  ICD code: ________  Date of diagnosis: ____________

 +20      ;;    ___ Non-Hodgkin's lymphoma

 +21      ;;                           ICD code: ________  Date of diagnosis: ____________

 +22      ;;    ___ Multiple myeloma   ICD code: ________  Date of diagnosis: ____________

 +23      ;;    ___ Myelodysplastic syndrome

 +24      ;;                           ICD code: ________  Date of diagnosis: ____________

 +25      ;;    ___ Plasmacytoma       ICD code: ________  Date of diagnosis: ____________

 +26      ;;    ___ Anemia (such as anemia of chronic disease, aplastic anemia, hemolytic

 +27      ;;        anemia, iron or vitamin-deficient anemias, thalassemias, myelophthisic

 +28      ;;        anemia, etc.)      ICD code: ________  Date of diagnosis: ____________

 +29      ;;    ___ Thrombocytopenia   ICD code: ________  Date of diagnosis: ____________

 +30      ;;    ___ Polycythemia vera  ICD code: ________  Date of diagnosis: ____________

 +31      ;;    ___ Sickle cell anemia ICD code: ________  Date of diagnosis: ____________

 +32      ;;    ___ Splenectomy        ICD code: ________  Date of diagnosis: ____________

 +33      ;;    ___ Hairy cell or other B-cell leukemia: If checked, complete Hairy cell

 +34      ;;        and other B-cell leukemias Questionnaire in lieu of this Questionnaire.

 +35      ;;    ___ Other, specify:

 +36      ;;           Other diagnosis #1: ___________________

 +37      ;;           ICD code: _____________________________

 +38      ;;           Date of diagnosis: ____________________

 +39      ;;

 +40      ;;           Other diagnosis #2: ___________________

 +41      ;;           ICD code: _____________________________

 +42      ;;           Date of diagnosis: ____________________

 +43      ;;

 +44      ;;           Other diagnosis #3: ___________________

 +45      ;;           ICD code: _____________________________

 +46      ;;           Date of diagnosis: ____________________

 +47      ;;

 +48      ;; If there are additional diagnoses that pertain to hematologic or lymphatic

 +49      ;; conditions, list using above format: ________________________________________

 +50      ;;^TOF^

 +51      ;; 2. Medical history

 +52      ;; a. Describe the history (including onset and course) of the Veteran's

 +53      ;; hematologic or lymphatic condition (brief summary):__________________________

 +54      ;;

 +55      ;; b. Is continuous medication required for control of a hematologic or lymphatic

 +56      ;; condition, including anemia or thrombocytopenia caused by treatment for a

 +57      ;; hematologic or lymphatic condition?

 +58      ;; ___ Yes   ___ No

 +59      ;; If yes, list only those medications required for control of the Veteran's

 +60      ;; hematologic or lymphatic condition, including anemia or thrombocytopenia

 +61      ;; caused by treatment for a hematologic or lymphatic condition. Provide the

 +62      ;; name of the medication and the condition the medication is used to treat:

 +63      ;; _____________________________________________________________________________

 +64      ;;

 +65      ;; c. Indicate the status of the primary hematologic or lymphatic condition:

 +66      ;;     ___ Active

 +67      ;;     ___ Remission

 +68      ;;     ___ Not applicable

 +69      ;;

 +70      ;; 3. Treatment

 +71      ;; a. Has the Veteran completed any treatment or is the Veteran currently

 +72      ;; undergoing any treatment for any hematologic or lymphatic condition,

 +73      ;; including leukemia?

 +74      ;; ___ Yes   ___ No; watchful waiting

 +75      ;; If yes, indicate type of treatment the Veteran is currently undergoing or has

 +76      ;; completed (check all that apply):

 +77      ;;    ___ Treatment completed; currently in watchful waiting status

 +78      ;;    ___ Bone marrow transplant

 +79      ;;        If checked, provide:

 +80      ;;        Date of hospital admission and location:  ____________________________

 +81      ;;        Date of hospital discharge after transplant: _________________________

 +82      ;;    ___ Surgery

 +83      ;;        If checked, describe: ________________________________________________

 +84      ;;        Date(s)of surgery: ___________________________________________________

 +85      ;;    ___ Radiation therapy

 +86      ;;        Date of most recent treatment: _______________________________________

 +87      ;;        Date of completion of treatment or anticipated date of

 +88      ;;        completion:___________________________________________________________

 +89      ;;    ___ Antineoplastic chemotherapy

 +90      ;;        Date of most recent treatment:________________________________________

 +91      ;;        Date of completion of treatment or anticipated date of

 +92      ;;        completion:___________________________________________________________

 +93      ;;    ___ Other therapeutic procedure

 +94      ;;              If checked, describe procedure: ________________________________

 +95      ;;              Date of most recent procedure: _________________________________

 +96      ;;    ___ Other therapeutic treatment

 +97      ;;              If checked, describe treatment: ________________________________

 +98      ;;              Date of completion of treatment or anticipated date of

 +99      ;;              completion: ____________________________________________________

 +100     ;;^TOF^

 +101     ;; 4. Anemia and thrombocytopenia (primary, secondary, idiopathic and immune)

 +102     ;; Does the Veteran have anemia or thrombocytopenia, including that caused by

 +103     ;; treatment for a hematologic or lymphatic condition?

 +104     ;; ___ Yes   ___ No

 +105     ;; If yes, complete the following:

 +106     ;;

 +107     ;; a. Does the Veteran have anemia?

 +108     ;; ___ Yes   ___ No

 +109     ;; If yes, is the anemia caused by treatment for another hematologic or lymphatic

 +110     ;; condition?

 +111     ;; ___ Yes   ___ No

 +112     ;; If yes, provide the name of the other hematologic or lymphatic condition

 +113     ;; causing the secondary anemia: _______________________________________________

 +114     ;;

 +115     ;; b. Does the Veteran have thrombocytopenia?

 +116     ;; ___ Yes   ___ No

 +117     ;; If yes, is the thrombocytopenia caused by treatment for another hematologic

 +118     ;; or lymphatic condition?

 +119     ;; ___ Yes   ___ No

 +120     ;; If yes, provide the name of the other hematologic or lymphatic condition

 +121     ;; causing the secondary thrombocytopenia: _____________________________________

 +122     ;;

 +123     ;; If the Veteran has thrombocytopenia, select the answer that best represents

 +124     ;; the Veteran's condition:

 +125     ;;    ___ Stable platelet count of 100,000 or more

 +126     ;;    ___ Stable platelet count between 70,000 and 100,000

 +127     ;;    ___ Platelet count between 20,000 and 70,000

 +128     ;;    ___ Platelet count of less than 20,000

 +129     ;;    ___ With active bleeding

 +130     ;;    ___ Other, describe: _____________________________________________________

 +131     ;;

 +132     ;; c. Does the Veteran have any complications or residuals of treatment requiring

 +133     ;; transfusion of platelets or red blood cells?

 +134     ;; ___ Yes   ___ No

 +135     ;; If yes, indicate frequency of transfusions in the past 12 months:

 +136     ;;    ___ None

 +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     ;;^TOF^

 +141     ;; 5. Findings, signs and symptoms

 +142     ;; Does the Veteran currently have any findings, signs and symptoms due to a

 +143     ;; hematologic or lymphatic disorder or to treatment for a hematologic or

 +144     ;; lymphatic disorder?

 +145     ;; ___ Yes   ___ No

 +146     ;; If yes, check all that apply:

 +147     ;;    ___ Weakness

 +148     ;;      If checked, describe: __________________________________________________

 +149     ;;    ___ Easy fatigability

 +150     ;;      If checked, describe: __________________________________________________

 +151     ;;    ___ Light-headedness

 +152     ;;      If checked, describe: __________________________________________________

 +153     ;;    ___ Shortness of breath

 +154     ;;      If checked, describe: __________________________________________________

 +155     ;;    ___ Headaches

 +156     ;;      If checked, describe: __________________________________________________

 +157     ;;    ___ Dyspnea on mild exertion

 +158     ;;      If checked, describe: __________________________________________________

 +159     ;;    ___ Dyspnea at rest

 +160     ;;      If checked, describe: __________________________________________________

 +161     ;;    ___ Tachycardia

 +162     ;;      If checked, describe: __________________________________________________

 +163     ;;    ___ Syncope

 +164     ;;      If checked, describe: __________________________________________________

 +165     ;;    ___ Cardiomegaly

 +166     ;;    ___ High output congestive heart failure

 +167     ;;    ___ Other, describe: _____________________________________________________

 +168     ;;

 +169     ;; 6. Recurring infections

 +170     ;; Does the Veteran currently have recurring infections attributable to any

 +171     ;; conditions, complications or residuals of treatment for a hematologic or

 +172     ;; lymphatic disorder?

 +173     ;; ___ Yes   ___ No

 +174     ;; If yes, indicate frequency of infections over past 12 months:

 +175     ;;    ___ None

 +176     ;;    ___ At least once per year but less than once every 3 months

 +177     ;;    ___ At least once every 3 months

 +178     ;;    ___ At least once every 6 weeks

 +179     ;;

 +180     ;; 7. Polycythemia vera

 +181     ;; Does the Veteran have polycythemia vera?

 +182     ;; ___ Yes   ___ No

 +183     ;; If yes, check all that apply:

 +184     ;;    ___ Stable, with or without continuous medication

 +185     ;;    ___ Requiring phlebotomy

 +186     ;;    ___ Requiring myelosuppressant treatment

 +187     ;;    ___ Other, describe: _____________________________________________________

 +188     ;;

 +189     ;; NOTE: If there are complications due to polycythemia vera such as hypertension,

 +190     ;; gout, stroke or thrombotic disease, ALSO complete appropriate Questionnaire

 +191     ;; for each condition.

 +192     ;;

 +193     ;; 8. Sickle cell anemia

 +194     ;; Does the Veteran have sickle cell anemia?

 +195     ;; ___ Yes   ___ No

 +196     ;; If yes, check all that apply:

 +197     ;;    ___ Asymptomatic

 +198     ;;    ___ In remission

 +199     ;;    ___ With identifiable organ impairment

 +200     ;;    ___ Following repeated hemolytic sickling crises with continuing

 +201     ;;        impairment of health

 +202     ;;    ___ Painful crises several times a year

 +203     ;;    ___ Repeated painful crises, occurring in skin, joints, bones or any

 +204     ;;        major organs

 +205     ;;    ___ With anemia, thrombosis and infarction

 +206     ;;    ___ Symptoms preclude other than light manual labor

 +207     ;;    ___ Symptoms preclude even light manual labor

 +208     ;;    ___ Other, describe: _____________________________________________________

 +209     ;;

 +210     ;; 9. Other pertinent physical findings, complications, conditions, signs

 +211     ;; and/or symptoms

 +212     ;; a. Does the Veteran have any scars (surgical or otherwise) related to any

 +213     ;; conditions or to the treatment of any conditions listed in the Diagnosis

 +214     ;; section above?

 +215     ;; ___ Yes   ___ No

 +216     ;; If yes, are any of the scars painful and/or unstable, or is the total area of

 +217     ;; all related scars greater than 39 square cm (6 square inches)?

 +218     ;; ___ Yes   ___ No

 +219     ;; If yes, also complete a Scars Questionnaire.

 +220     ;;

 +221     ;; b. Does the Veteran have any other pertinent physical findings, complications,

 +222     ;; conditions, signs and/or symptoms?

 +223     ;; ___ Yes   ___ No

 +224     ;; If yes, describe (brief summary): ___________________________________________

 +225     ;;

 +226     ;; 10. Diagnostic testing

 +227     ;; If testing has been performed and reflects Veteran's current condition, no

 +228     ;; further testing is required.

 +229     ;; When appropriate, provide most recent complete blood count.

 +230     ;;

 +231     ;; a. Has laboratory testing been performed?

 +232     ;; ___ Yes   ___ No

 +233     ;; If yes, provide results:

 +234     ;;    Hemoglobin (gm/100ml): __________________________  Date: _________________

 +235     ;;    Hematocrit: _____________________________________  Date: _________________

 +236     ;;    Red blood cell (RBC) count: _____________________  Date: _________________

 +237     ;;    White blood cell (WBC) count: ___________________  Date: _________________

 +238     ;;    White blood cell differential count: ____________  Date: _________________

 +239     ;;    Platelet count: _________________________________  Date: _________________

 +240     ;;

 +241     ;; b. Are there any other significant diagnostic test findings and/or results?

 +242     ;; ___ Yes   ___ No

 +243     ;; If yes, provide type of test or procedure, date and results (brief summary):

 +244     ;; _____________________________________________________________________________

 +245     ;;

 +246     ;; 11. Functional impact

 +247     ;;

 +248     ;; Do the Veteran's hematologic or lymphatic condition(s) impact his or

 +249     ;; her ability to work?

 +250     ;; ___ Yes   ___ No

 +251     ;; If yes, describe impact of each of the Veteran's hematologic and lymphatic

 +252     ;; conditions, providing one or more examples: _________________________________

 +253     ;; _____________________________________________________________________________

 +254     ;;

 +255     ;; 12. Remarks, if any:_________________________________________________________

 +256     ;; _____________________________________________________________________________

 +257     ;;

 +258     ;; Physician signature: _____________________________________ Date: ____________

 +259     ;;

 +260     ;; Physician printed name: __________________________________ Phone: ___________

 +261     ;;

 +262     ;; Medical license #: _______________________________________ Fax: _____________

 +263     ;;

 +264     ;; Physician address: __________________________________________________________

 +265     ;;

 +266     ;; NOTE: VA may request additional medical information, including additional

 +267     ;; examinations if necessary to complete VA's review of the Veteran's

 +268     ;; application.

 +269     ;;^END^

 +270      QUIT

DVBCQHA6.m