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Routine: DVBCQHD3

DVBCQHD3.m

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  1. DVBCQHD3 ;;ALB-CIOFO/ECF -  HEART CONDITION QUESTIONNAIRE ; 6/15/2011
  1.  ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; 12. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;;
  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
  1.  ;; of 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,
  1.  ;; complications, conditions, signs and/or symptoms related to any conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): ______________________________________
  1.  ;;
  1.  ;; 13. Diagnostic Testing
  1.  ;;
  1.  ;; For VA purposes, exams for all heart conditions require a determination of
  1.  ;; whether or not cardiac hypertrophy or dilatation is present. The
  1.  ;; suggested order of testing for cardiac hypertrophy/dilatation is EKG, then
  1.  ;; chest x-ray (PA and lateral), then echocardiogram. An echocardiogram to
  1.  ;; determine heart size is only necessary if the other two tests are negative.
  1.  ;;
  1.  ;; For VA purposes, if LVEF testing is not of record, but available medical
  1.  ;; information sufficiently reflects the severity of the Veteran's
  1.  ;; cardiovascular condition, LVEF testing is not required.
  1.  ;;^TOF^
  1.  ;; a. Is there evidence of cardiac hypertrophy?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate how this condition was documented:
  1.  ;; ___ EKG   ___ Chest x-ray   ___ Echocardiogram
  1.  ;;     Date of test: _________________
  1.  ;;
  1.  ;; b. Is there evidence of cardiac dilatation?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate how this condition was documented:
  1.  ;; ___ Chest x-ray   ___ Echocardiogram
  1.  ;;     Date of test: _________________
  1.  ;;
  1.  ;; c. Diagnostic tests
  1.  ;; Indicate all testing completed; provide only most recent results which
  1.  ;; reflect the Veterans current functional status (check all that apply):
  1.  ;; ___ EKG      Date of EKG: _______________________
  1.  ;;     Result:  ___ Normal
  1.  ;;              ___ Arrhythmia, describe:  ____________________________________
  1.  ;;              ___ Hypertrophy, describe:  ___________________________________
  1.  ;;              ___ Ischemia, describe:  ______________________________________
  1.  ;;              ___ Other, describe:  _________________________________________
  1.  ;; ___ Chest x-ray  Date of CXR: ___________________________
  1.  ;;     Result:  ___ Normal   ___ Abnormal, describe: __________________________
  1.  ;; ___ Echocardiogram   Date of echocardiogram: ____________
  1.  ;;        Left ventricular ejection fraction (LVEF): ______%
  1.  ;;        Wall motion:    ___ Normal   ___ Abnormal, describe: ________________
  1.  ;;        Wall thickness: ___ Normal   ___ Abnormal, describe: ________________
  1.  ;; ___ Holter monitor   Date of Holter monitor: ____________
  1.  ;;     Result:  ___ Normal   ___ Abnormal, describe: __________________________
  1.  ;; ___ MUGA         Date of MUGA: __________________________
  1.  ;;     Left ventricular ejection fraction (LVEF): _________%
  1.  ;;     Result:  ___ Normal   ___ Abnormal, describe: __________________________
  1.  ;; ___ Coronary artery angiogram      Date of angiogram: ______________
  1.  ;;     Result:  ___ Normal   ___ Abnormal, describe: __________________________
  1.  ;; ___ CT angiography   Date of CT angiography: ____________
  1.  ;;     Result:  ___ Normal   ___ Abnormal, describe: __________________________
  1.  ;; ___ Other test, specify: ___________________________________________________
  1.  ;;     Date: ________________
  1.  ;;     Result: ______________
  1.  ;;
  1.  ;; 14. METs Testing
  1.  ;;
  1.  ;; NOTE: For VA purposes, all heart exams require METs testing (either
  1.  ;; exercise-based or interview-based) to determine the activity level at
  1.  ;; which symptoms such as dyspnea, fatigue, angina, dizziness, or syncope
  1.  ;; develop (except exams for supraventricular arrhythmias).
  1.  ;;^TOF^
  1.  ;; If a laboratory determination of METs by exercise testing cannot be done
  1.  ;; for medical reasons (e.g chronic CHF or multiple episodes of acute CHF
  1.  ;; within the past 12 months), or if exercise-based METs test was not
  1.  ;; completed because it is not required as part of the Veteran's treatment
  1.  ;; plan, or if exercise stress test results do not reflect Veteran's current
  1.  ;; cardiac function, perform an interview-based METs test based on the
  1.  ;; Veteran's responses to a cardiac activity questionnaire and provide the
  1.  ;; results below.
  1.  ;;
  1.  ;; Indicate all testing completed; provide only most recent results which
  1.  ;; reflect the Veterans current functional status(check all that apply):
  1.  ;;
  1.  ;; a. ___ Exercise stress test
  1.  ;; Date of most recent exercise stress test: ________________
  1.  ;; Results: ___________________________________________________________________
  1.  ;; METs level the Veteran performed, if provided: ___________
  1.  ;;
  1.  ;; b. ___ Interview-based METs test
  1.  ;; Date of interview-based METs test: ______________
  1.  ;;
  1.  ;; Symptoms during activity:
  1.  ;; The METs level checked below reflects the lowest activity level at which
  1.  ;; the Veteran reports any of the following symptoms (check all symptoms that
  1.  ;; the Veteran reports at the indicated METs level of activity):
  1.  ;; ___ Dyspnea   ___ Fatigue   ___ Angina   ___ Dizziness   ___ Syncope
  1.  ;; ___ Other, describe: _______________________________________________________
  1.  ;;
  1.  ;; Results:
  1.  ;; METs level on most recent interview-based METs test:
  1.  ;;   ___(1-3 METs)   This METs level has been found to be consistent with
  1.  ;;                   activities such as eating, dressing, taking a shower, slow
  1.  ;;                   walking (2 mph) for 1-2 blocks
  1.  ;;   ___(>3-5 METs)  This METs level has been found to be consistent with
  1.  ;;                   activities such as light yard work (weeding), mowing lawn
  1.  ;;                   (power mower), brisk walking (4 mph)
  1.  ;;   ___(>5-7 METs)  This METs level has been found to be consistent with
  1.  ;;                   activities such as walking 1 flight of stairs, golfing
  1.  ;;                   (without cart), mowing lawn (push mower), heavy yard work
  1.  ;;                   (digging)
  1.  ;;   ___(>7-10 METs) This METs level has been found to be consistent with
  1.  ;;                   activities such as climbing stairs quickly, moderate
  1.  ;;                   bicycling, sawing wood, jogging (6 mph)
  1.  ;;   ___ The Veteran denies experiencing symptoms with any level of physical
  1.  ;;       activity
  1.  ;;
  1.  ;; c. If the Veteran has had both an exercise stress test and an interview-
  1.  ;; based METs test, indicate which results most accurately reflect the
  1.  ;; Veteran's current cardiac functional level:
  1.  ;;    ___ Exercise stress test   ___ Interview-based METs test   ___ N/A
  1.  ;;^TOF^
  1.  ;; d. Is the METs level limitation due solely to the heart condition(s)?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If no, estimate the percentage of the METs level limitation that is due
  1.  ;; solely to the heart condition(s):
  1.  ;; __ 0%  __ 10%  __ 20%  __ 30%  __ 40%  __ 50%  __ 60%  __ 70%
  1.  ;; __ 80%  __ 90%
  1.  ;; __ The limitation in METs level is due to multiple factors; it is not
  1.  ;; possible to accurately estimate this percentage
  1.  ;;
  1.  ;; e. In addition to the heart condition(s), does the Veteran have other
  1.  ;; non-cardiac medical conditions (such as musculoskeletal or pulmonary
  1.  ;; conditions) limiting the METs level?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, identify each condition and describe how each non-cardiac medical
  1.  ;; condition limits the Veteran's METs level:
  1.  ;;    Other medical condition #1: ________ Effect on METs level: ______________
  1.  ;;    Other medical condition #2: ________ Effect on METs level: ______________
  1.  ;;    If there are additional medical conditions affecting METs level, list
  1.  ;;    using above format: _____________________________________________________
  1.  ;;
  1.  ;; 15. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's heart condition(s) impact his or her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe impact of each of the Veteran's heart conditions,
  1.  ;; providing one or more examples: ____________________________________________
  1.  ;; 
  1.  ;; 16. Remarks, if any:  ______________________________________________________
  1.  ;;
  1.  ;; Physician signature: _____________________________________ Date: ___________
  1.  ;;
  1.  ;; Physician printed name: ____________________________________________________
  1.  ;;
  1.  ;; Medical license #: _________________________________________________________
  1.  ;;
  1.  ;; Physician address: _________________________________________________________
  1.  ;;
  1.  ;; Phone: _____________________________     FAX: ______________________________
  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.  ;;
  1.  ;;^END^
  1.  Q