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^
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQHA6 13931 printed Apr 09, 2024@20:50:23 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
