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Routine: DVBCQHD2

DVBCQHD2.m

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  1. DVBCQHD2 ;;ALB-CIOFO/ECF - HEART CONDITION QUESTIONNAIRE ; 6/15/2011
  1. ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
  1. ;
  1. TXT ;
  1. ;;
  1. ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA)
  1. ;; for disability benefits. VA will consider the information you provide on
  1. ;; this questionnaire as part of their evaluation in processing the Veteran's
  1. ;; claim.
  1. ;;
  1. ;; 1. Diagnosis
  1. ;;
  1. ;; Does the Veteran now have or has he/she ever been diagnosed with a heart
  1. ;; condition?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, select the Veteran's heart condition(s) (check all that apply):
  1. ;;
  1. ;; ___ Acute, subacute, or old myocardial infarction
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Atherosclerotic cardiovascular disease
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Coronary artery disease
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Stable angina ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Unstable angina
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Coronary spasm, including Prinzmetal's angina
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Congestive heart failure
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Supraventricular arrhythmia
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Ventricular arrhythmia
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Heart block ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Valvular heart disease
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Heart valve replacement
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Cardiomyopathy ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Hypertensive heart disease
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Heart transplant
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Implanted cardiac pacemaker
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Implanted automatic implantable cardioverter defibrillator (AICD)
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;;^TOF^
  1. ;; ___ Infectious heart conditions (including active valvular infection,
  1. ;; rheumatic heart disease, endocarditis, pericarditis or syphilitic
  1. ;; heart disease)
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Pericardial adhesions
  1. ;; ICD code: ________ Date of diagnosis: ___________
  1. ;; ___ Other heart condition, specify below
  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. ;; If there are additional diagnoses that pertain to heart conditions, list
  1. ;; using above format: ________________________________________________________
  1. ;;
  1. ;; 2. Medical History
  1. ;;
  1. ;; a. Describe the history (including onset and course) of the Veteran's heart
  1. ;; condition(s) (brief summary):
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; b. Do any of the Veteran's heart conditions qualify within the generally
  1. ;; accepted medical definition of ischemic heart disease (IHD)?
  1. ;; ___ Yes ___ No
  1. ;; If yes, list the conditions that qualify: __________________________________
  1. ;;
  1. ;; c. Provide the etiology, if known, of each of the Veteran's heart
  1. ;; conditions, including the relationship/causality to other heart conditions,
  1. ;; particularly the relationship/causality to the Veteran's IHD conditions,
  1. ;; if any:
  1. ;;
  1. ;; Heart condition #1: Provide etiology ____________________________________
  1. ;;
  1. ;; Heart condition #2: Provide etiology ____________________________________
  1. ;;
  1. ;; If there are additional heart conditions, list and provide etiology,
  1. ;; using above format: _____________________________________________________
  1. ;;
  1. ;; d. Is continuous medication required for control of the Veteran's heart
  1. ;; condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, list medications required for the Veteran's heart condition (include
  1. ;; name of medication and heart condition it is used for, such as atenolol for
  1. ;; myocardial infarction or atrial fibrillation): _____________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;^TOF^
  1. ;; 3. Myocardial infarction (MI)
  1. ;;
  1. ;; Has the Veteran had a myocardial infarction (MI)?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following:
  1. ;;
  1. ;; MI #1: Date and treatment facility: _____________________________________
  1. ;; MI #2: Date and treatment facility: _____________________________________
  1. ;; If the Veteran has had additional MIs, list using above format: _________
  1. ;;
  1. ;; _________________________________________________________________________
  1. ;;
  1. ;; 4. Congestive Heart Failure (CHF)
  1. ;;
  1. ;; Has the Veteran had congestive heart failure (CHF)?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following:
  1. ;;
  1. ;; a. Does the Veteran have chronic CHF?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; b. Has the Veteran had any episodes of acute CHF in the past year?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following:
  1. ;;
  1. ;; Specify number of episodes of acute CHF the Veteran has had in the
  1. ;; past year:
  1. ;; ___ 0 ___ 1 ___ More than 1
  1. ;; Provide date of most recent episode of acute CHF: _______________________
  1. ;;
  1. ;; Was the Veteran admitted for treatment of acute CHF?
  1. ;; ___ Yes ___ No
  1. ;; If, yes, indicate name of treatment facility: ___________________________
  1. ;;
  1. ;; 5. Arrhythmia
  1. ;;
  1. ;; Has the Veteran had a cardiac arrhythmia?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following:
  1. ;;
  1. ;; Type of arrhythmia (check all that apply):
  1. ;; ___ Atrial fibrillation
  1. ;; If checked, indicate frequency:
  1. ;; ___ Constant ___ Intermittent (paroxysmal)
  1. ;; If intermittent, indicate number of episodes in the past 12 months:
  1. ;; ___ 0 ___ 1-4 ___ More than 4
  1. ;; Indicate how these episodes were documented (check all that apply)
  1. ;; ___ EKG ___ Holter ___ Other, specify: _____________________
  1. ;;^TOF^
  1. ;; ___ Atrial flutter
  1. ;; If checked, indicate frequency:
  1. ;; ___ Constant ___ Intermittent (paroxysmal)
  1. ;; If intermittent, indicate number of episodes in the past 12 months:
  1. ;; ___ 0 ___ 1-4 ___ More than 4
  1. ;; Indicate how these episodes were documented (check all that apply)
  1. ;; ___ EKG ___ Holter ___ Other, specify: _____________________
  1. ;;
  1. ;; ___ Supraventricular tachycardia
  1. ;; If checked, indicate frequency:
  1. ;; ___ Constant ___ Intermittent (paroxysmal)
  1. ;; If intermittent, indicate number of episodes in the past 12 months:
  1. ;; ___ 0 ___ 1-4 ___ More than 4
  1. ;; Indicate how these episodes were documented (check all that apply)
  1. ;; ___ EKG ___ Holter ___ Other, specify: _____________________
  1. ;;
  1. ;; ___ Atrioventricular block
  1. ;; ___ I degree ___ II degree ___ III degree
  1. ;;
  1. ;; ___ Ventricular arrhythmia (sustained)
  1. ;; Indicate date of hospital admission for initial evaluation and
  1. ;; medical treatment in the Procedures section below
  1. ;;
  1. ;; ___ Other cardiac arrhythmia, specify: __________________________________
  1. ;; If checked, indicate frequency:
  1. ;; ___ Constant ___ Intermittent (paroxysmal)
  1. ;; If intermittent, indicate number of episodes in the past 12 months:
  1. ;; ___ 0 ___ 1-3 ___ More than 4
  1. ;; Indicate how these episodes were documented (check all that apply)
  1. ;; ___ EKG ___ Holter ___ Other, specify: _____________________
  1. ;;
  1. ;; 6. Heart valve conditions
  1. ;;
  1. ;; Has the Veteran had a heart valve condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following:
  1. ;;
  1. ;; a. Valves affected (check all that apply):
  1. ;; ___ Mitral ___ Tricuspid ___ Aortic ___ Pulmonary
  1. ;;
  1. ;; b. Describe type of valve condition for each checked valve: ________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;^TOF^
  1. ;; 7. Infectious heart conditions
  1. ;;
  1. ;; Has the Veteran had any infectious cardiac conditions, including active
  1. ;; valvular infection (including rheumatic heart disease), endocarditis,
  1. ;; pericarditis or syphilitic heart disease?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following:
  1. ;;
  1. ;; a. Has the Veteran undergone or is the Veteran currently undergoing treatment
  1. ;; for an active infection?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe treatment and site of infection being treated: ____________
  1. ;; Has treatment for an active infection been completed?
  1. ;; ___ Yes ___ No
  1. ;; Date completed: ____________________
  1. ;;
  1. ;; b. Has the Veteran had a syphilitic aortic aneurysm?
  1. ;; ___ Yes ___ No
  1. ;; If yes, ALSO complete Artery and Vein Conditions Questionnaire.
  1. ;;
  1. ;; 8. Pericardial adhesions
  1. ;;
  1. ;; Has the Veteran had pericardial adhesions?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following:
  1. ;;
  1. ;; Etiology of pericardial adhesions:
  1. ;; ___ Pericarditis ___ Cardiac surgery/bypass
  1. ;; ___Other, describe: ________________________________________________________
  1. ;;
  1. ;; 9. Procedures
  1. ;;
  1. ;; Has the Veteran had any non-surgical or surgical procedures for the
  1. ;; treatment of a heart condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, indicate the non-surgical or surgical procedures the Veteran has
  1. ;; had for the treatment of heart conditions (check all that apply):
  1. ;;
  1. ;; ___ Percutaneous coronary intervention (PCI) (angioplasty)
  1. ;; Indicate date of treatment or date of admission if admitted for
  1. ;; treatment and treatment facility: ___________________________________
  1. ;; ___ Coronary artery bypass surgery
  1. ;; Indicate date of admission for treatment and treatment facility:
  1. ;; _____________________________________________________________________
  1. ;; ___ Heart valve replacement
  1. ;; Specify valve(s) replaced and type of valve(s): _____________________
  1. ;; Indicate date of admission for treatment and treatment facility:
  1. ;; _____________________________________________________________________
  1. ;;^TOF^
  1. ;; ___ Heart transplant:
  1. ;; Indicate date of admission for treatment and treatment facility:
  1. ;; _____________________________________________________________________
  1. ;; ___ Implanted cardiac pacemaker
  1. ;; Indicate date of admission for treatment and treatment facility:
  1. ;; _____________________________________________________________________
  1. ;; ___ Implanted automatic implantable cardioverter defibrillator (AICD)
  1. ;; Indicate date of admission for treatment and treatment facility:
  1. ;; _____________________________________________________________________
  1. ;; ___ Valve replacement
  1. ;; If checked, indicate valve(s) that have been replaced (check all that
  1. ;; apply):
  1. ;; ___ Mitral ___ Tricuspid ___ Aortic ___ Pulmonary
  1. ;; Indicate date of admission for treatment and treatment facility for
  1. ;; each checked valve: _________________________________________________
  1. ;; ___ Ventricular aneurysmectomy
  1. ;; Indicate date of admission for treatment and treatment facility:
  1. ;; _____________________________________________________________________
  1. ;; ___ Other surgical and/or non-surgical procedures for the treatment of a
  1. ;; heart condition, describe: __________________________________________
  1. ;; Indicate date of admission for treatment and treatment facility:
  1. ;; _____________________________________________________________________
  1. ;; Indicate the condition that resulted in the need for this
  1. ;; procedure/treatment: ________________________________________________
  1. ;;
  1. ;; 10. Hospitalizations
  1. ;;
  1. ;; Has the Veteran had any other hospitalizations for the treatment of heart
  1. ;; conditions (other than for non-surgical and surgical procedures described
  1. ;; above)?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following:
  1. ;;
  1. ;; a. Date of admission for treatment and treatment facility: _________________
  1. ;;_____________________________________________________________________________
  1. ;;
  1. ;; b. Condition that resulted in the need for hospitalization: ________________
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; 11. Physical exam
  1. ;;
  1. ;; a. Heart rate: ________
  1. ;; b. Rhythm: ___ Regular ___ Irregular
  1. ;; c. Point of maximal impact: ___ Not palpable
  1. ;; ___ 4th intercostal space
  1. ;; ___ 5th intercostal space
  1. ;; ___ Other, specify: ____________________________
  1. ;; d. Heart sounds: ___ Normal ___ Abnormal, specify: _______________________
  1. ;; e. Jugular-venous distension: ___ Yes ___ No
  1. ;;^TOF^
  1. ;; f. Auscultation of the lungs ___ Clear ___ Bibasilar rales
  1. ;; ___ Other, describe: _________________________
  1. ;; g. Peripheral pulses:
  1. ;; Dorsalis pedis: ___ Normal ___ Diminished ___ Absent
  1. ;; Posterior tibial: ___ Normal ___ Diminished ___ Absent
  1. ;; h. Peripheral edema:
  1. ;; Right lower extremity: __ None __ Trace __ 1+ __ 2+ __ 3+ __ 4+
  1. ;; Left lower extremity: __ None __ Trace __ 1+ __ 2+ __ 3+ __ 4+
  1. ;; i. Blood pressure: ________________
  1. ;;
  1. Q