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Routine: DVBCQHA8

DVBCQHA8.m

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  1. DVBCQHA8 ;;ALB-CIOFO/SBW - HEMATOLOGIC INCLUDING ANEMIA QUESTIONNAIRE (V4) ; 30/JUL/2011
  1.  ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
  1.  ;
  1. TXT ;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1.  ;; disability benefits.  VA will consider the information you provide on this
  1.  ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with a hematologic
  1.  ;; or lymphatic condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, select the Veteran's condition(s) (check all that apply):
  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.  ;;    ___ Chronic lymphocytic leukemia (CLL)
  1.  ;;                           ICD code: ________  Date of diagnosis: ____________
  1.  ;;    ___ Hodgkin's disease  ICD code: ________  Date of diagnosis: ____________
  1.  ;;    ___ Non-Hodgkin's lymphoma
  1.  ;;                           ICD code: ________  Date of diagnosis: ____________
  1.  ;;    ___ Multiple myeloma   ICD code: ________  Date of diagnosis: ____________
  1.  ;;    ___ Myelodysplastic syndrome
  1.  ;;                           ICD code: ________  Date of diagnosis: ____________
  1.  ;;    ___ Plasmacytoma       ICD code: ________  Date of diagnosis: ____________
  1.  ;;    ___ Anemia (such as anemia of chronic disease, aplastic anemia, hemolytic
  1.  ;;        anemia, iron or vitamin-deficient anemias, thalassemias, myelophthisic
  1.  ;;        anemia, etc.)      ICD code: ________  Date of diagnosis: ____________
  1.  ;;    ___ Thrombocytopenia   ICD code: ________  Date of diagnosis: ____________
  1.  ;;    ___ Polycythemia vera  ICD code: ________  Date of diagnosis: ____________
  1.  ;;    ___ Sickle cell anemia ICD code: ________  Date of diagnosis: ____________
  1.  ;;    ___ Splenectomy        ICD code: ________  Date of diagnosis: ____________
  1.  ;;    ___ Hairy cell or other B-cell leukemia: If checked, complete Hairy cell
  1.  ;;        and other B-cell leukemias Questionnaire in lieu of this Questionnaire.
  1.  ;;    ___ Other, specify:
  1.  ;;           Other diagnosis #1: ___________________
  1.  ;;           ICD code: _____________________________
  1.  ;;           Date of diagnosis: ____________________
  1.  ;;
  1.  ;;           Other diagnosis #2: ___________________
  1.  ;;           ICD code: _____________________________
  1.  ;;           Date of diagnosis: ____________________
  1.  ;;
  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.  ;; conditions, list using above format: ________________________________________
  1.  ;;^TOF^
  1.  ;; 2. Medical history
  1.  ;; a. Describe the history (including onset and course) of the Veteran's
  1.  ;; hematologic or lymphatic condition (brief summary):__________________________
  1.  ;;
  1.  ;; b. Is continuous medication required for control of a hematologic or lymphatic
  1.  ;; condition, including anemia or thrombocytopenia caused by treatment for a 
  1.  ;; hematologic or lymphatic condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, list only those medications required for control of the Veteran's
  1.  ;; hematologic or lymphatic condition, including anemia or thrombocytopenia
  1.  ;; caused by treatment for a hematologic or lymphatic condition. Provide the 
  1.  ;; name of the medication and the condition the medication is used to treat:
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; c. Indicate the status of the primary hematologic or lymphatic condition:
  1.  ;;     ___ Active
  1.  ;;     ___ Remission
  1.  ;;     ___ Not applicable
  1.  ;;
  1.  ;; 3. Treatment
  1.  ;; a. Has the Veteran completed any treatment or is the Veteran currently
  1.  ;; undergoing any treatment for any hematologic or lymphatic condition,
  1.  ;; including leukemia?
  1.  ;; ___ Yes   ___ No; watchful waiting
  1.  ;; If yes, indicate type of treatment the Veteran is currently undergoing or has
  1.  ;; completed (check all that apply):
  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 
  1.  ;;        completion:___________________________________________________________
  1.  ;;    ___ Antineoplastic chemotherapy
  1.  ;;        Date of most recent treatment:________________________________________
  1.  ;;        Date of completion of treatment or anticipated date of
  1.  ;;        completion:___________________________________________________________
  1.  ;;    ___ Other therapeutic procedure
  1.  ;;              If checked, describe procedure: ________________________________ 
  1.  ;;              Date of most recent procedure: _________________________________
  1.  ;;    ___ Other therapeutic treatment
  1.  ;;              If checked, describe treatment: ________________________________
  1.  ;;              Date of completion of treatment or anticipated date of
  1.  ;;              completion: ____________________________________________________
  1.  ;;^TOF^
  1.  ;; 4. Anemia and thrombocytopenia (primary, secondary, idiopathic and immune)
  1.  ;; Does the Veteran have anemia or thrombocytopenia, including that caused by
  1.  ;; treatment for a hematologic or lymphatic condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete the following:
  1.  ;;
  1.  ;; a. Does the Veteran have anemia?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, is the anemia caused by treatment for another hematologic or lymphatic
  1.  ;; condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide the name of the other hematologic or lymphatic condition
  1.  ;; causing the secondary anemia: _______________________________________________
  1.  ;;
  1.  ;; b. Does the Veteran have thrombocytopenia?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, is the thrombocytopenia caused by treatment for another hematologic
  1.  ;; or lymphatic condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide the name of the other hematologic or lymphatic condition
  1.  ;; causing the secondary thrombocytopenia: _____________________________________
  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.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;
  1.  ;; c. Does the Veteran have any complications or residuals of treatment requiring
  1.  ;; transfusion of platelets or red blood cells?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate frequency of transfusions in the past 12 months:
  1.  ;;    ___ None
  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.  ;;^TOF^
  1.  ;; 5. Findings, signs and symptoms
  1.  ;; Does the Veteran currently have any findings, signs and symptoms due to a 
  1.  ;; hematologic or lymphatic disorder or to treatment for a hematologic or
  1.  ;; lymphatic disorder?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply: 
  1.  ;;    ___ Weakness
  1.  ;;      If checked, describe: __________________________________________________
  1.  ;;    ___ Easy fatigability
  1.  ;;      If checked, describe: __________________________________________________
  1.  ;;    ___ Light-headedness
  1.  ;;      If checked, describe: __________________________________________________
  1.  ;;    ___ Shortness of breath
  1.  ;;      If checked, describe: __________________________________________________
  1.  ;;    ___ Headaches
  1.  ;;      If checked, describe: __________________________________________________
  1.  ;;    ___ Dyspnea on mild exertion
  1.  ;;      If checked, describe: __________________________________________________
  1.  ;;    ___ Dyspnea at rest
  1.  ;;      If checked, describe: __________________________________________________
  1.  ;;    ___ Tachycardia
  1.  ;;      If checked, describe: __________________________________________________
  1.  ;;    ___ Syncope
  1.  ;;      If checked, describe: __________________________________________________
  1.  ;;    ___ Cardiomegaly
  1.  ;;    ___ High output congestive heart failure
  1.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;
  1.  ;; 6. Recurring infections
  1.  ;; Does the Veteran currently have recurring infections attributable to any
  1.  ;; conditions, complications or residuals of treatment for a hematologic or 
  1.  ;; lymphatic disorder?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate frequency of infections over past 12 months:
  1.  ;;    ___ None
  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.  ;; 7. Polycythemia vera
  1.  ;; Does the Veteran have polycythemia vera?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Stable, with or without continuous medication
  1.  ;;    ___ Requiring phlebotomy
  1.  ;;    ___ Requiring myelosuppressant treatment
  1.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;
  1.  ;; NOTE: If there are complications due to polycythemia vera such as hypertension,
  1.  ;; gout, stroke or thrombotic disease, ALSO complete appropriate Questionnaire
  1.  ;; for each condition.
  1.  ;;^TOF^
  1.  ;; 8. Sickle cell anemia
  1.  ;; Does the Veteran have sickle cell anemia?
  1.  ;; ___ Yes   ___ No
  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.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;
  1.  ;; 9. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis 
  1.  ;; section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, are any of the scars painful and/or unstable, or is the total area of
  1.  ;; all related scars greater than 39 square cm (6 square inches)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, also complete a Scars Questionnaire.
  1.  ;;
  1.  ;; b. Does the Veteran have any other pertinent physical findings, complications,
  1.  ;; conditions, signs and/or symptoms?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): ___________________________________________
  1.  ;;
  1.  ;; 10. Diagnostic testing
  1.  ;; If testing has been performed and reflects Veteran's current condition, no 
  1.  ;; further testing is required.
  1.  ;; When appropriate, provide most recent complete blood count.
  1.  ;;
  1.  ;; a. Has laboratory testing been performed?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide results:
  1.  ;;    Hemoglobin (gm/100ml): __________________________  Date: _________________
  1.  ;;    Hematocrit: _____________________________________  Date: _________________
  1.  ;;    Red blood cell (RBC) count: _____________________  Date: _________________
  1.  ;;    White blood cell (WBC) count: ___________________  Date: _________________
  1.  ;;    White blood cell differential count: ____________  Date: _________________
  1.  ;;    Platelet count: _________________________________  Date: _________________
  1.  ;;^TOF^
  1.  ;; b. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 11. Functional impact
  1.  ;;
  1.  ;; Do the Veteran's hematologic or lymphatic condition(s) impact his or
  1.  ;; her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe impact of each of the Veteran's hematologic and lymphatic
  1.  ;; conditions, providing one or more examples: _________________________________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 12. Remarks, if any:_________________________________________________________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; Physician signature: _____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: __________________________________ Phone: ___________
  1.  ;;
  1.  ;; Medical license #: _______________________________________ Fax: _____________
  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.  ;;^END^
  1.  Q