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 Apr 09, 2024@20:57:20 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
