- DVBCQHD2 ;;ALB-CIOFO/ECF - HEART CONDITION QUESTIONNAIRE ; 6/15/2011
- ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
- ;
- 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 heart
- ;; condition?
- ;; ___ Yes ___ No
- ;;
- ;; If yes, select the Veteran's heart condition(s) (check all that apply):
- ;;
- ;; ___ Acute, subacute, or old myocardial infarction
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Atherosclerotic cardiovascular disease
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Coronary artery disease
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Stable angina ICD code: ________ Date of diagnosis: ___________
- ;; ___ Unstable angina
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Coronary spasm, including Prinzmetal's angina
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Congestive heart failure
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Supraventricular arrhythmia
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Ventricular arrhythmia
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Heart block ICD code: ________ Date of diagnosis: ___________
- ;; ___ Valvular heart disease
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Heart valve replacement
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Cardiomyopathy ICD code: ________ Date of diagnosis: ___________
- ;; ___ Hypertensive heart disease
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Heart transplant
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Implanted cardiac pacemaker
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Implanted automatic implantable cardioverter defibrillator (AICD)
- ;; ICD code: ________ Date of diagnosis: ___________
- ;;^TOF^
- ;; ___ Infectious heart conditions (including active valvular infection,
- ;; rheumatic heart disease, endocarditis, pericarditis or syphilitic
- ;; heart disease)
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Pericardial adhesions
- ;; ICD code: ________ Date of diagnosis: ___________
- ;; ___ Other heart condition, specify below
- ;; Other diagnosis #1: _____________
- ;; ICD code: ______________________
- ;; Date of diagnosis: ______________
- ;;
- ;; Other diagnosis #2: _____________
- ;; ICD code: ______________________
- ;; Date of diagnosis: ______________
- ;;
- ;; If there are additional diagnoses that pertain to heart conditions, list
- ;; using above format: ________________________________________________________
- ;;
- ;; 2. Medical History
- ;;
- ;; a. Describe the history (including onset and course) of the Veteran's heart
- ;; condition(s) (brief summary):
- ;; ____________________________________________________________________________
- ;;
- ;; b. Do any of the Veteran's heart conditions qualify within the generally
- ;; accepted medical definition of ischemic heart disease (IHD)?
- ;; ___ Yes ___ No
- ;; If yes, list the conditions that qualify: __________________________________
- ;;
- ;; c. Provide the etiology, if known, of each of the Veteran's heart
- ;; conditions, including the relationship/causality to other heart conditions,
- ;; particularly the relationship/causality to the Veteran's IHD conditions,
- ;; if any:
- ;;
- ;; Heart condition #1: Provide etiology ____________________________________
- ;;
- ;; Heart condition #2: Provide etiology ____________________________________
- ;;
- ;; If there are additional heart conditions, list and provide etiology,
- ;; using above format: _____________________________________________________
- ;;
- ;; d. Is continuous medication required for control of the Veteran's heart
- ;; condition?
- ;; ___ Yes ___ No
- ;; If yes, list medications required for the Veteran's heart condition (include
- ;; name of medication and heart condition it is used for, such as atenolol for
- ;; myocardial infarction or atrial fibrillation): _____________________________
- ;;
- ;; ____________________________________________________________________________
- ;;^TOF^
- ;; 3. Myocardial infarction (MI)
- ;;
- ;; Has the Veteran had a myocardial infarction (MI)?
- ;; ___ Yes ___ No
- ;; If yes, complete the following:
- ;;
- ;; MI #1: Date and treatment facility: _____________________________________
- ;; MI #2: Date and treatment facility: _____________________________________
- ;; If the Veteran has had additional MIs, list using above format: _________
- ;;
- ;; _________________________________________________________________________
- ;;
- ;; 4. Congestive Heart Failure (CHF)
- ;;
- ;; Has the Veteran had congestive heart failure (CHF)?
- ;; ___ Yes ___ No
- ;; If yes, complete the following:
- ;;
- ;; a. Does the Veteran have chronic CHF?
- ;; ___ Yes ___ No
- ;;
- ;; b. Has the Veteran had any episodes of acute CHF in the past year?
- ;; ___ Yes ___ No
- ;; If yes, complete the following:
- ;;
- ;; Specify number of episodes of acute CHF the Veteran has had in the
- ;; past year:
- ;; ___ 0 ___ 1 ___ More than 1
- ;; Provide date of most recent episode of acute CHF: _______________________
- ;;
- ;; Was the Veteran admitted for treatment of acute CHF?
- ;; ___ Yes ___ No
- ;; If, yes, indicate name of treatment facility: ___________________________
- ;;
- ;; 5. Arrhythmia
- ;;
- ;; Has the Veteran had a cardiac arrhythmia?
- ;; ___ Yes ___ No
- ;; If yes, complete the following:
- ;;
- ;; Type of arrhythmia (check all that apply):
- ;; ___ Atrial fibrillation
- ;; If checked, indicate frequency:
- ;; ___ Constant ___ Intermittent (paroxysmal)
- ;; If intermittent, indicate number of episodes in the past 12 months:
- ;; ___ 0 ___ 1-4 ___ More than 4
- ;; Indicate how these episodes were documented (check all that apply)
- ;; ___ EKG ___ Holter ___ Other, specify: _____________________
- ;;^TOF^
- ;; ___ Atrial flutter
- ;; If checked, indicate frequency:
- ;; ___ Constant ___ Intermittent (paroxysmal)
- ;; If intermittent, indicate number of episodes in the past 12 months:
- ;; ___ 0 ___ 1-4 ___ More than 4
- ;; Indicate how these episodes were documented (check all that apply)
- ;; ___ EKG ___ Holter ___ Other, specify: _____________________
- ;;
- ;; ___ Supraventricular tachycardia
- ;; If checked, indicate frequency:
- ;; ___ Constant ___ Intermittent (paroxysmal)
- ;; If intermittent, indicate number of episodes in the past 12 months:
- ;; ___ 0 ___ 1-4 ___ More than 4
- ;; Indicate how these episodes were documented (check all that apply)
- ;; ___ EKG ___ Holter ___ Other, specify: _____________________
- ;;
- ;; ___ Atrioventricular block
- ;; ___ I degree ___ II degree ___ III degree
- ;;
- ;; ___ Ventricular arrhythmia (sustained)
- ;; Indicate date of hospital admission for initial evaluation and
- ;; medical treatment in the Procedures section below
- ;;
- ;; ___ Other cardiac arrhythmia, specify: __________________________________
- ;; If checked, indicate frequency:
- ;; ___ Constant ___ Intermittent (paroxysmal)
- ;; If intermittent, indicate number of episodes in the past 12 months:
- ;; ___ 0 ___ 1-3 ___ More than 4
- ;; Indicate how these episodes were documented (check all that apply)
- ;; ___ EKG ___ Holter ___ Other, specify: _____________________
- ;;
- ;; 6. Heart valve conditions
- ;;
- ;; Has the Veteran had a heart valve condition?
- ;; ___ Yes ___ No
- ;; If yes, complete the following:
- ;;
- ;; a. Valves affected (check all that apply):
- ;; ___ Mitral ___ Tricuspid ___ Aortic ___ Pulmonary
- ;;
- ;; b. Describe type of valve condition for each checked valve: ________________
- ;;
- ;; ____________________________________________________________________________
- ;;^TOF^
- ;; 7. Infectious heart conditions
- ;;
- ;; Has the Veteran had any infectious cardiac conditions, including active
- ;; valvular infection (including rheumatic heart disease), endocarditis,
- ;; pericarditis or syphilitic heart disease?
- ;; ___ Yes ___ No
- ;; If yes, complete the following:
- ;;
- ;; a. Has the Veteran undergone or is the Veteran currently undergoing treatment
- ;; for an active infection?
- ;; ___ Yes ___ No
- ;; If yes, describe treatment and site of infection being treated: ____________
- ;; Has treatment for an active infection been completed?
- ;; ___ Yes ___ No
- ;; Date completed: ____________________
- ;;
- ;; b. Has the Veteran had a syphilitic aortic aneurysm?
- ;; ___ Yes ___ No
- ;; If yes, ALSO complete Artery and Vein Conditions Questionnaire.
- ;;
- ;; 8. Pericardial adhesions
- ;;
- ;; Has the Veteran had pericardial adhesions?
- ;; ___ Yes ___ No
- ;; If yes, complete the following:
- ;;
- ;; Etiology of pericardial adhesions:
- ;; ___ Pericarditis ___ Cardiac surgery/bypass
- ;; ___Other, describe: ________________________________________________________
- ;;
- ;; 9. Procedures
- ;;
- ;; Has the Veteran had any non-surgical or surgical procedures for the
- ;; treatment of a heart condition?
- ;; ___ Yes ___ No
- ;; If yes, indicate the non-surgical or surgical procedures the Veteran has
- ;; had for the treatment of heart conditions (check all that apply):
- ;;
- ;; ___ Percutaneous coronary intervention (PCI) (angioplasty)
- ;; Indicate date of treatment or date of admission if admitted for
- ;; treatment and treatment facility: ___________________________________
- ;; ___ Coronary artery bypass surgery
- ;; Indicate date of admission for treatment and treatment facility:
- ;; _____________________________________________________________________
- ;; ___ Heart valve replacement
- ;; Specify valve(s) replaced and type of valve(s): _____________________
- ;; Indicate date of admission for treatment and treatment facility:
- ;; _____________________________________________________________________
- ;;^TOF^
- ;; ___ Heart transplant:
- ;; Indicate date of admission for treatment and treatment facility:
- ;; _____________________________________________________________________
- ;; ___ Implanted cardiac pacemaker
- ;; Indicate date of admission for treatment and treatment facility:
- ;; _____________________________________________________________________
- ;; ___ Implanted automatic implantable cardioverter defibrillator (AICD)
- ;; Indicate date of admission for treatment and treatment facility:
- ;; _____________________________________________________________________
- ;; ___ Valve replacement
- ;; If checked, indicate valve(s) that have been replaced (check all that
- ;; apply):
- ;; ___ Mitral ___ Tricuspid ___ Aortic ___ Pulmonary
- ;; Indicate date of admission for treatment and treatment facility for
- ;; each checked valve: _________________________________________________
- ;; ___ Ventricular aneurysmectomy
- ;; Indicate date of admission for treatment and treatment facility:
- ;; _____________________________________________________________________
- ;; ___ Other surgical and/or non-surgical procedures for the treatment of a
- ;; heart condition, describe: __________________________________________
- ;; Indicate date of admission for treatment and treatment facility:
- ;; _____________________________________________________________________
- ;; Indicate the condition that resulted in the need for this
- ;; procedure/treatment: ________________________________________________
- ;;
- ;; 10. Hospitalizations
- ;;
- ;; Has the Veteran had any other hospitalizations for the treatment of heart
- ;; conditions (other than for non-surgical and surgical procedures described
- ;; above)?
- ;; ___ Yes ___ No
- ;; If yes, complete the following:
- ;;
- ;; a. Date of admission for treatment and treatment facility: _________________
- ;;_____________________________________________________________________________
- ;;
- ;; b. Condition that resulted in the need for hospitalization: ________________
- ;; ____________________________________________________________________________
- ;;
- ;; 11. Physical exam
- ;;
- ;; a. Heart rate: ________
- ;; b. Rhythm: ___ Regular ___ Irregular
- ;; c. Point of maximal impact: ___ Not palpable
- ;; ___ 4th intercostal space
- ;; ___ 5th intercostal space
- ;; ___ Other, specify: ____________________________
- ;; d. Heart sounds: ___ Normal ___ Abnormal, specify: _______________________
- ;; e. Jugular-venous distension: ___ Yes ___ No
- ;;^TOF^
- ;; f. Auscultation of the lungs ___ Clear ___ Bibasilar rales
- ;; ___ Other, describe: _________________________
- ;; g. Peripheral pulses:
- ;; Dorsalis pedis: ___ Normal ___ Diminished ___ Absent
- ;; Posterior tibial: ___ Normal ___ Diminished ___ Absent
- ;; h. Peripheral edema:
- ;; Right lower extremity: __ None __ Trace __ 1+ __ 2+ __ 3+ __ 4+
- ;; Left lower extremity: __ None __ Trace __ 1+ __ 2+ __ 3+ __ 4+
- ;; i. Blood pressure: ________________
- ;;
- Q
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQHD2 14459 printed Feb 18, 2025@23:12:57 Page 2
- DVBCQHD2 ;;ALB-CIOFO/ECF - HEART CONDITION QUESTIONNAIRE ; 6/15/2011
- +1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
- +2 ;
- TXT ;
- +1 ;;
- +2 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA)
- +3 ;; for disability benefits. VA will consider the information you provide on
- +4 ;; this questionnaire as part of their evaluation in processing the Veteran's
- +5 ;; claim.
- +6 ;;
- +7 ;; 1. Diagnosis
- +8 ;;
- +9 ;; Does the Veteran now have or has he/she ever been diagnosed with a heart
- +10 ;; condition?
- +11 ;; ___ Yes ___ No
- +12 ;;
- +13 ;; If yes, select the Veteran's heart condition(s) (check all that apply):
- +14 ;;
- +15 ;; ___ Acute, subacute, or old myocardial infarction
- +16 ;; ICD code: ________ Date of diagnosis: ___________
- +17 ;; ___ Atherosclerotic cardiovascular disease
- +18 ;; ICD code: ________ Date of diagnosis: ___________
- +19 ;; ___ Coronary artery disease
- +20 ;; ICD code: ________ Date of diagnosis: ___________
- +21 ;; ___ Stable angina ICD code: ________ Date of diagnosis: ___________
- +22 ;; ___ Unstable angina
- +23 ;; ICD code: ________ Date of diagnosis: ___________
- +24 ;; ___ Coronary spasm, including Prinzmetal's angina
- +25 ;; ICD code: ________ Date of diagnosis: ___________
- +26 ;; ___ Congestive heart failure
- +27 ;; ICD code: ________ Date of diagnosis: ___________
- +28 ;; ___ Supraventricular arrhythmia
- +29 ;; ICD code: ________ Date of diagnosis: ___________
- +30 ;; ___ Ventricular arrhythmia
- +31 ;; ICD code: ________ Date of diagnosis: ___________
- +32 ;; ___ Heart block ICD code: ________ Date of diagnosis: ___________
- +33 ;; ___ Valvular heart disease
- +34 ;; ICD code: ________ Date of diagnosis: ___________
- +35 ;; ___ Heart valve replacement
- +36 ;; ICD code: ________ Date of diagnosis: ___________
- +37 ;; ___ Cardiomyopathy ICD code: ________ Date of diagnosis: ___________
- +38 ;; ___ Hypertensive heart disease
- +39 ;; ICD code: ________ Date of diagnosis: ___________
- +40 ;; ___ Heart transplant
- +41 ;; ICD code: ________ Date of diagnosis: ___________
- +42 ;; ___ Implanted cardiac pacemaker
- +43 ;; ICD code: ________ Date of diagnosis: ___________
- +44 ;; ___ Implanted automatic implantable cardioverter defibrillator (AICD)
- +45 ;; ICD code: ________ Date of diagnosis: ___________
- +46 ;;^TOF^
- +47 ;; ___ Infectious heart conditions (including active valvular infection,
- +48 ;; rheumatic heart disease, endocarditis, pericarditis or syphilitic
- +49 ;; heart disease)
- +50 ;; ICD code: ________ Date of diagnosis: ___________
- +51 ;; ___ Pericardial adhesions
- +52 ;; ICD code: ________ Date of diagnosis: ___________
- +53 ;; ___ Other heart condition, specify below
- +54 ;; Other diagnosis #1: _____________
- +55 ;; ICD code: ______________________
- +56 ;; Date of diagnosis: ______________
- +57 ;;
- +58 ;; Other diagnosis #2: _____________
- +59 ;; ICD code: ______________________
- +60 ;; Date of diagnosis: ______________
- +61 ;;
- +62 ;; If there are additional diagnoses that pertain to heart conditions, list
- +63 ;; using above format: ________________________________________________________
- +64 ;;
- +65 ;; 2. Medical History
- +66 ;;
- +67 ;; a. Describe the history (including onset and course) of the Veteran's heart
- +68 ;; condition(s) (brief summary):
- +69 ;; ____________________________________________________________________________
- +70 ;;
- +71 ;; b. Do any of the Veteran's heart conditions qualify within the generally
- +72 ;; accepted medical definition of ischemic heart disease (IHD)?
- +73 ;; ___ Yes ___ No
- +74 ;; If yes, list the conditions that qualify: __________________________________
- +75 ;;
- +76 ;; c. Provide the etiology, if known, of each of the Veteran's heart
- +77 ;; conditions, including the relationship/causality to other heart conditions,
- +78 ;; particularly the relationship/causality to the Veteran's IHD conditions,
- +79 ;; if any:
- +80 ;;
- +81 ;; Heart condition #1: Provide etiology ____________________________________
- +82 ;;
- +83 ;; Heart condition #2: Provide etiology ____________________________________
- +84 ;;
- +85 ;; If there are additional heart conditions, list and provide etiology,
- +86 ;; using above format: _____________________________________________________
- +87 ;;
- +88 ;; d. Is continuous medication required for control of the Veteran's heart
- +89 ;; condition?
- +90 ;; ___ Yes ___ No
- +91 ;; If yes, list medications required for the Veteran's heart condition (include
- +92 ;; name of medication and heart condition it is used for, such as atenolol for
- +93 ;; myocardial infarction or atrial fibrillation): _____________________________
- +94 ;;
- +95 ;; ____________________________________________________________________________
- +96 ;;^TOF^
- +97 ;; 3. Myocardial infarction (MI)
- +98 ;;
- +99 ;; Has the Veteran had a myocardial infarction (MI)?
- +100 ;; ___ Yes ___ No
- +101 ;; If yes, complete the following:
- +102 ;;
- +103 ;; MI #1: Date and treatment facility: _____________________________________
- +104 ;; MI #2: Date and treatment facility: _____________________________________
- +105 ;; If the Veteran has had additional MIs, list using above format: _________
- +106 ;;
- +107 ;; _________________________________________________________________________
- +108 ;;
- +109 ;; 4. Congestive Heart Failure (CHF)
- +110 ;;
- +111 ;; Has the Veteran had congestive heart failure (CHF)?
- +112 ;; ___ Yes ___ No
- +113 ;; If yes, complete the following:
- +114 ;;
- +115 ;; a. Does the Veteran have chronic CHF?
- +116 ;; ___ Yes ___ No
- +117 ;;
- +118 ;; b. Has the Veteran had any episodes of acute CHF in the past year?
- +119 ;; ___ Yes ___ No
- +120 ;; If yes, complete the following:
- +121 ;;
- +122 ;; Specify number of episodes of acute CHF the Veteran has had in the
- +123 ;; past year:
- +124 ;; ___ 0 ___ 1 ___ More than 1
- +125 ;; Provide date of most recent episode of acute CHF: _______________________
- +126 ;;
- +127 ;; Was the Veteran admitted for treatment of acute CHF?
- +128 ;; ___ Yes ___ No
- +129 ;; If, yes, indicate name of treatment facility: ___________________________
- +130 ;;
- +131 ;; 5. Arrhythmia
- +132 ;;
- +133 ;; Has the Veteran had a cardiac arrhythmia?
- +134 ;; ___ Yes ___ No
- +135 ;; If yes, complete the following:
- +136 ;;
- +137 ;; Type of arrhythmia (check all that apply):
- +138 ;; ___ Atrial fibrillation
- +139 ;; If checked, indicate frequency:
- +140 ;; ___ Constant ___ Intermittent (paroxysmal)
- +141 ;; If intermittent, indicate number of episodes in the past 12 months:
- +142 ;; ___ 0 ___ 1-4 ___ More than 4
- +143 ;; Indicate how these episodes were documented (check all that apply)
- +144 ;; ___ EKG ___ Holter ___ Other, specify: _____________________
- +145 ;;^TOF^
- +146 ;; ___ Atrial flutter
- +147 ;; If checked, indicate frequency:
- +148 ;; ___ Constant ___ Intermittent (paroxysmal)
- +149 ;; If intermittent, indicate number of episodes in the past 12 months:
- +150 ;; ___ 0 ___ 1-4 ___ More than 4
- +151 ;; Indicate how these episodes were documented (check all that apply)
- +152 ;; ___ EKG ___ Holter ___ Other, specify: _____________________
- +153 ;;
- +154 ;; ___ Supraventricular tachycardia
- +155 ;; If checked, indicate frequency:
- +156 ;; ___ Constant ___ Intermittent (paroxysmal)
- +157 ;; If intermittent, indicate number of episodes in the past 12 months:
- +158 ;; ___ 0 ___ 1-4 ___ More than 4
- +159 ;; Indicate how these episodes were documented (check all that apply)
- +160 ;; ___ EKG ___ Holter ___ Other, specify: _____________________
- +161 ;;
- +162 ;; ___ Atrioventricular block
- +163 ;; ___ I degree ___ II degree ___ III degree
- +164 ;;
- +165 ;; ___ Ventricular arrhythmia (sustained)
- +166 ;; Indicate date of hospital admission for initial evaluation and
- +167 ;; medical treatment in the Procedures section below
- +168 ;;
- +169 ;; ___ Other cardiac arrhythmia, specify: __________________________________
- +170 ;; If checked, indicate frequency:
- +171 ;; ___ Constant ___ Intermittent (paroxysmal)
- +172 ;; If intermittent, indicate number of episodes in the past 12 months:
- +173 ;; ___ 0 ___ 1-3 ___ More than 4
- +174 ;; Indicate how these episodes were documented (check all that apply)
- +175 ;; ___ EKG ___ Holter ___ Other, specify: _____________________
- +176 ;;
- +177 ;; 6. Heart valve conditions
- +178 ;;
- +179 ;; Has the Veteran had a heart valve condition?
- +180 ;; ___ Yes ___ No
- +181 ;; If yes, complete the following:
- +182 ;;
- +183 ;; a. Valves affected (check all that apply):
- +184 ;; ___ Mitral ___ Tricuspid ___ Aortic ___ Pulmonary
- +185 ;;
- +186 ;; b. Describe type of valve condition for each checked valve: ________________
- +187 ;;
- +188 ;; ____________________________________________________________________________
- +189 ;;^TOF^
- +190 ;; 7. Infectious heart conditions
- +191 ;;
- +192 ;; Has the Veteran had any infectious cardiac conditions, including active
- +193 ;; valvular infection (including rheumatic heart disease), endocarditis,
- +194 ;; pericarditis or syphilitic heart disease?
- +195 ;; ___ Yes ___ No
- +196 ;; If yes, complete the following:
- +197 ;;
- +198 ;; a. Has the Veteran undergone or is the Veteran currently undergoing treatment
- +199 ;; for an active infection?
- +200 ;; ___ Yes ___ No
- +201 ;; If yes, describe treatment and site of infection being treated: ____________
- +202 ;; Has treatment for an active infection been completed?
- +203 ;; ___ Yes ___ No
- +204 ;; Date completed: ____________________
- +205 ;;
- +206 ;; b. Has the Veteran had a syphilitic aortic aneurysm?
- +207 ;; ___ Yes ___ No
- +208 ;; If yes, ALSO complete Artery and Vein Conditions Questionnaire.
- +209 ;;
- +210 ;; 8. Pericardial adhesions
- +211 ;;
- +212 ;; Has the Veteran had pericardial adhesions?
- +213 ;; ___ Yes ___ No
- +214 ;; If yes, complete the following:
- +215 ;;
- +216 ;; Etiology of pericardial adhesions:
- +217 ;; ___ Pericarditis ___ Cardiac surgery/bypass
- +218 ;; ___Other, describe: ________________________________________________________
- +219 ;;
- +220 ;; 9. Procedures
- +221 ;;
- +222 ;; Has the Veteran had any non-surgical or surgical procedures for the
- +223 ;; treatment of a heart condition?
- +224 ;; ___ Yes ___ No
- +225 ;; If yes, indicate the non-surgical or surgical procedures the Veteran has
- +226 ;; had for the treatment of heart conditions (check all that apply):
- +227 ;;
- +228 ;; ___ Percutaneous coronary intervention (PCI) (angioplasty)
- +229 ;; Indicate date of treatment or date of admission if admitted for
- +230 ;; treatment and treatment facility: ___________________________________
- +231 ;; ___ Coronary artery bypass surgery
- +232 ;; Indicate date of admission for treatment and treatment facility:
- +233 ;; _____________________________________________________________________
- +234 ;; ___ Heart valve replacement
- +235 ;; Specify valve(s) replaced and type of valve(s): _____________________
- +236 ;; Indicate date of admission for treatment and treatment facility:
- +237 ;; _____________________________________________________________________
- +238 ;;^TOF^
- +239 ;; ___ Heart transplant:
- +240 ;; Indicate date of admission for treatment and treatment facility:
- +241 ;; _____________________________________________________________________
- +242 ;; ___ Implanted cardiac pacemaker
- +243 ;; Indicate date of admission for treatment and treatment facility:
- +244 ;; _____________________________________________________________________
- +245 ;; ___ Implanted automatic implantable cardioverter defibrillator (AICD)
- +246 ;; Indicate date of admission for treatment and treatment facility:
- +247 ;; _____________________________________________________________________
- +248 ;; ___ Valve replacement
- +249 ;; If checked, indicate valve(s) that have been replaced (check all that
- +250 ;; apply):
- +251 ;; ___ Mitral ___ Tricuspid ___ Aortic ___ Pulmonary
- +252 ;; Indicate date of admission for treatment and treatment facility for
- +253 ;; each checked valve: _________________________________________________
- +254 ;; ___ Ventricular aneurysmectomy
- +255 ;; Indicate date of admission for treatment and treatment facility:
- +256 ;; _____________________________________________________________________
- +257 ;; ___ Other surgical and/or non-surgical procedures for the treatment of a
- +258 ;; heart condition, describe: __________________________________________
- +259 ;; Indicate date of admission for treatment and treatment facility:
- +260 ;; _____________________________________________________________________
- +261 ;; Indicate the condition that resulted in the need for this
- +262 ;; procedure/treatment: ________________________________________________
- +263 ;;
- +264 ;; 10. Hospitalizations
- +265 ;;
- +266 ;; Has the Veteran had any other hospitalizations for the treatment of heart
- +267 ;; conditions (other than for non-surgical and surgical procedures described
- +268 ;; above)?
- +269 ;; ___ Yes ___ No
- +270 ;; If yes, complete the following:
- +271 ;;
- +272 ;; a. Date of admission for treatment and treatment facility: _________________
- +273 ;;_____________________________________________________________________________
- +274 ;;
- +275 ;; b. Condition that resulted in the need for hospitalization: ________________
- +276 ;; ____________________________________________________________________________
- +277 ;;
- +278 ;; 11. Physical exam
- +279 ;;
- +280 ;; a. Heart rate: ________
- +281 ;; b. Rhythm: ___ Regular ___ Irregular
- +282 ;; c. Point of maximal impact: ___ Not palpable
- +283 ;; ___ 4th intercostal space
- +284 ;; ___ 5th intercostal space
- +285 ;; ___ Other, specify: ____________________________
- +286 ;; d. Heart sounds: ___ Normal ___ Abnormal, specify: _______________________
- +287 ;; e. Jugular-venous distension: ___ Yes ___ No
- +288 ;;^TOF^
- +289 ;; f. Auscultation of the lungs ___ Clear ___ Bibasilar rales
- +290 ;; ___ Other, describe: _________________________
- +291 ;; g. Peripheral pulses:
- +292 ;; Dorsalis pedis: ___ Normal ___ Diminished ___ Absent
- +293 ;; Posterior tibial: ___ Normal ___ Diminished ___ Absent
- +294 ;; h. Peripheral edema:
- +295 ;; Right lower extremity: __ None __ Trace __ 1+ __ 2+ __ 3+ __ 4+
- +296 ;; Left lower extremity: __ None __ Trace __ 1+ __ 2+ __ 3+ __ 4+
- +297 ;; i. Blood pressure: ________________
- +298 ;;
- +299 QUIT