DVBCQHD3 ;;ALB-CIOFO/ECF - HEART CONDITION QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
;
TXT ;
;;
;; 12. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;;
;; a. Does the Veteran have any scars (surgical or otherwise) related to any
;; conditions or to the treatment of any conditions listed in the Diagnosis
;; section above?
;; ___ Yes ___ No
;; If yes, are any of the scars painful and/or unstable, or is the total area
;; of all related scars greater than 39 square cm (6 square inches)?
;; ___ Yes ___ No
;; If yes, also complete a Scars Questionnaire.
;;
;; b. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs and/or symptoms related to any conditions
;; listed in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): ______________________________________
;;
;; 13. Diagnostic Testing
;;
;; For VA purposes, exams for all heart conditions require a determination of
;; whether or not cardiac hypertrophy or dilatation is present. The
;; suggested order of testing for cardiac hypertrophy/dilatation is EKG, then
;; chest x-ray (PA and lateral), then echocardiogram. An echocardiogram to
;; determine heart size is only necessary if the other two tests are negative.
;;
;; For VA purposes, if LVEF testing is not of record, but available medical
;; information sufficiently reflects the severity of the Veteran's
;; cardiovascular condition, LVEF testing is not required.
;;^TOF^
;; a. Is there evidence of cardiac hypertrophy?
;; ___ Yes ___ No
;; If yes, indicate how this condition was documented:
;; ___ EKG ___ Chest x-ray ___ Echocardiogram
;; Date of test: _________________
;;
;; b. Is there evidence of cardiac dilatation?
;; ___ Yes ___ No
;; If yes, indicate how this condition was documented:
;; ___ Chest x-ray ___ Echocardiogram
;; Date of test: _________________
;;
;; c. Diagnostic tests
;; Indicate all testing completed; provide only most recent results which
;; reflect the Veterans current functional status (check all that apply):
;; ___ EKG Date of EKG: _______________________
;; Result: ___ Normal
;; ___ Arrhythmia, describe: ____________________________________
;; ___ Hypertrophy, describe: ___________________________________
;; ___ Ischemia, describe: ______________________________________
;; ___ Other, describe: _________________________________________
;; ___ Chest x-ray Date of CXR: ___________________________
;; Result: ___ Normal ___ Abnormal, describe: __________________________
;; ___ Echocardiogram Date of echocardiogram: ____________
;; Left ventricular ejection fraction (LVEF): ______%
;; Wall motion: ___ Normal ___ Abnormal, describe: ________________
;; Wall thickness: ___ Normal ___ Abnormal, describe: ________________
;; ___ Holter monitor Date of Holter monitor: ____________
;; Result: ___ Normal ___ Abnormal, describe: __________________________
;; ___ MUGA Date of MUGA: __________________________
;; Left ventricular ejection fraction (LVEF): _________%
;; Result: ___ Normal ___ Abnormal, describe: __________________________
;; ___ Coronary artery angiogram Date of angiogram: ______________
;; Result: ___ Normal ___ Abnormal, describe: __________________________
;; ___ CT angiography Date of CT angiography: ____________
;; Result: ___ Normal ___ Abnormal, describe: __________________________
;; ___ Other test, specify: ___________________________________________________
;; Date: ________________
;; Result: ______________
;;
;; 14. METs Testing
;;
;; NOTE: For VA purposes, all heart exams require METs testing (either
;; exercise-based or interview-based) to determine the activity level at
;; which symptoms such as dyspnea, fatigue, angina, dizziness, or syncope
;; develop (except exams for supraventricular arrhythmias).
;;^TOF^
;; If a laboratory determination of METs by exercise testing cannot be done
;; for medical reasons (e.g chronic CHF or multiple episodes of acute CHF
;; within the past 12 months), or if exercise-based METs test was not
;; completed because it is not required as part of the Veteran's treatment
;; plan, or if exercise stress test results do not reflect Veteran's current
;; cardiac function, perform an interview-based METs test based on the
;; Veteran's responses to a cardiac activity questionnaire and provide the
;; results below.
;;
;; Indicate all testing completed; provide only most recent results which
;; reflect the Veterans current functional status(check all that apply):
;;
;; a. ___ Exercise stress test
;; Date of most recent exercise stress test: ________________
;; Results: ___________________________________________________________________
;; METs level the Veteran performed, if provided: ___________
;;
;; b. ___ Interview-based METs test
;; Date of interview-based METs test: ______________
;;
;; Symptoms during activity:
;; The METs level checked below reflects the lowest activity level at which
;; the Veteran reports any of the following symptoms (check all symptoms that
;; the Veteran reports at the indicated METs level of activity):
;; ___ Dyspnea ___ Fatigue ___ Angina ___ Dizziness ___ Syncope
;; ___ Other, describe: _______________________________________________________
;;
;; Results:
;; METs level on most recent interview-based METs test:
;; ___(1-3 METs) This METs level has been found to be consistent with
;; activities such as eating, dressing, taking a shower, slow
;; walking (2 mph) for 1-2 blocks
;; ___(>3-5 METs) This METs level has been found to be consistent with
;; activities such as light yard work (weeding), mowing lawn
;; (power mower), brisk walking (4 mph)
;; ___(>5-7 METs) This METs level has been found to be consistent with
;; activities such as walking 1 flight of stairs, golfing
;; (without cart), mowing lawn (push mower), heavy yard work
;; (digging)
;; ___(>7-10 METs) This METs level has been found to be consistent with
;; activities such as climbing stairs quickly, moderate
;; bicycling, sawing wood, jogging (6 mph)
;; ___ The Veteran denies experiencing symptoms with any level of physical
;; activity
;;
;; c. If the Veteran has had both an exercise stress test and an interview-
;; based METs test, indicate which results most accurately reflect the
;; Veteran's current cardiac functional level:
;; ___ Exercise stress test ___ Interview-based METs test ___ N/A
;;^TOF^
;; d. Is the METs level limitation due solely to the heart condition(s)?
;; ___ Yes ___ No
;;
;; If no, estimate the percentage of the METs level limitation that is due
;; solely to the heart condition(s):
;; __ 0% __ 10% __ 20% __ 30% __ 40% __ 50% __ 60% __ 70%
;; __ 80% __ 90%
;; __ The limitation in METs level is due to multiple factors; it is not
;; possible to accurately estimate this percentage
;;
;; e. In addition to the heart condition(s), does the Veteran have other
;; non-cardiac medical conditions (such as musculoskeletal or pulmonary
;; conditions) limiting the METs level?
;; ___ Yes ___ No
;;
;; If yes, identify each condition and describe how each non-cardiac medical
;; condition limits the Veteran's METs level:
;; Other medical condition #1: ________ Effect on METs level: ______________
;; Other medical condition #2: ________ Effect on METs level: ______________
;; If there are additional medical conditions affecting METs level, list
;; using above format: _____________________________________________________
;;
;; 15. Functional impact
;;
;; Does the Veteran's heart condition(s) impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe impact of each of the Veteran's heart conditions,
;; providing one or more examples: ____________________________________________
;;
;; 16. Remarks, if any: ______________________________________________________
;;
;; Physician signature: _____________________________________ Date: ___________
;;
;; Physician printed name: ____________________________________________________
;;
;; Medical license #: _________________________________________________________
;;
;; Physician address: _________________________________________________________
;;
;; Phone: _____________________________ FAX: ______________________________
;;
;; NOTE: VA may request additional medical information, including additional
;; examinations if necessary to complete VA's review of the Veteran's
;; application.
;;
;;^END^
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQHD3 9165 printed Apr 09, 2024@20:59:19 Page 2
DVBCQHD3 ;;ALB-CIOFO/ECF - HEART CONDITION QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;;
+2 ;; 12. Other pertinent physical findings, complications, conditions, signs
+3 ;; and/or symptoms
+4 ;;
+5 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+6 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+7 ;; section above?
+8 ;; ___ Yes ___ No
+9 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+10 ;; of all related scars greater than 39 square cm (6 square inches)?
+11 ;; ___ Yes ___ No
+12 ;; If yes, also complete a Scars Questionnaire.
+13 ;;
+14 ;; b. Does the Veteran have any other pertinent physical findings,
+15 ;; complications, conditions, signs and/or symptoms related to any conditions
+16 ;; listed in the Diagnosis section above?
+17 ;; ___ Yes ___ No
+18 ;; If yes, describe (brief summary): ______________________________________
+19 ;;
+20 ;; 13. Diagnostic Testing
+21 ;;
+22 ;; For VA purposes, exams for all heart conditions require a determination of
+23 ;; whether or not cardiac hypertrophy or dilatation is present. The
+24 ;; suggested order of testing for cardiac hypertrophy/dilatation is EKG, then
+25 ;; chest x-ray (PA and lateral), then echocardiogram. An echocardiogram to
+26 ;; determine heart size is only necessary if the other two tests are negative.
+27 ;;
+28 ;; For VA purposes, if LVEF testing is not of record, but available medical
+29 ;; information sufficiently reflects the severity of the Veteran's
+30 ;; cardiovascular condition, LVEF testing is not required.
+31 ;;^TOF^
+32 ;; a. Is there evidence of cardiac hypertrophy?
+33 ;; ___ Yes ___ No
+34 ;; If yes, indicate how this condition was documented:
+35 ;; ___ EKG ___ Chest x-ray ___ Echocardiogram
+36 ;; Date of test: _________________
+37 ;;
+38 ;; b. Is there evidence of cardiac dilatation?
+39 ;; ___ Yes ___ No
+40 ;; If yes, indicate how this condition was documented:
+41 ;; ___ Chest x-ray ___ Echocardiogram
+42 ;; Date of test: _________________
+43 ;;
+44 ;; c. Diagnostic tests
+45 ;; Indicate all testing completed; provide only most recent results which
+46 ;; reflect the Veterans current functional status (check all that apply):
+47 ;; ___ EKG Date of EKG: _______________________
+48 ;; Result: ___ Normal
+49 ;; ___ Arrhythmia, describe: ____________________________________
+50 ;; ___ Hypertrophy, describe: ___________________________________
+51 ;; ___ Ischemia, describe: ______________________________________
+52 ;; ___ Other, describe: _________________________________________
+53 ;; ___ Chest x-ray Date of CXR: ___________________________
+54 ;; Result: ___ Normal ___ Abnormal, describe: __________________________
+55 ;; ___ Echocardiogram Date of echocardiogram: ____________
+56 ;; Left ventricular ejection fraction (LVEF): ______%
+57 ;; Wall motion: ___ Normal ___ Abnormal, describe: ________________
+58 ;; Wall thickness: ___ Normal ___ Abnormal, describe: ________________
+59 ;; ___ Holter monitor Date of Holter monitor: ____________
+60 ;; Result: ___ Normal ___ Abnormal, describe: __________________________
+61 ;; ___ MUGA Date of MUGA: __________________________
+62 ;; Left ventricular ejection fraction (LVEF): _________%
+63 ;; Result: ___ Normal ___ Abnormal, describe: __________________________
+64 ;; ___ Coronary artery angiogram Date of angiogram: ______________
+65 ;; Result: ___ Normal ___ Abnormal, describe: __________________________
+66 ;; ___ CT angiography Date of CT angiography: ____________
+67 ;; Result: ___ Normal ___ Abnormal, describe: __________________________
+68 ;; ___ Other test, specify: ___________________________________________________
+69 ;; Date: ________________
+70 ;; Result: ______________
+71 ;;
+72 ;; 14. METs Testing
+73 ;;
+74 ;; NOTE: For VA purposes, all heart exams require METs testing (either
+75 ;; exercise-based or interview-based) to determine the activity level at
+76 ;; which symptoms such as dyspnea, fatigue, angina, dizziness, or syncope
+77 ;; develop (except exams for supraventricular arrhythmias).
+78 ;;^TOF^
+79 ;; If a laboratory determination of METs by exercise testing cannot be done
+80 ;; for medical reasons (e.g chronic CHF or multiple episodes of acute CHF
+81 ;; within the past 12 months), or if exercise-based METs test was not
+82 ;; completed because it is not required as part of the Veteran's treatment
+83 ;; plan, or if exercise stress test results do not reflect Veteran's current
+84 ;; cardiac function, perform an interview-based METs test based on the
+85 ;; Veteran's responses to a cardiac activity questionnaire and provide the
+86 ;; results below.
+87 ;;
+88 ;; Indicate all testing completed; provide only most recent results which
+89 ;; reflect the Veterans current functional status(check all that apply):
+90 ;;
+91 ;; a. ___ Exercise stress test
+92 ;; Date of most recent exercise stress test: ________________
+93 ;; Results: ___________________________________________________________________
+94 ;; METs level the Veteran performed, if provided: ___________
+95 ;;
+96 ;; b. ___ Interview-based METs test
+97 ;; Date of interview-based METs test: ______________
+98 ;;
+99 ;; Symptoms during activity:
+100 ;; The METs level checked below reflects the lowest activity level at which
+101 ;; the Veteran reports any of the following symptoms (check all symptoms that
+102 ;; the Veteran reports at the indicated METs level of activity):
+103 ;; ___ Dyspnea ___ Fatigue ___ Angina ___ Dizziness ___ Syncope
+104 ;; ___ Other, describe: _______________________________________________________
+105 ;;
+106 ;; Results:
+107 ;; METs level on most recent interview-based METs test:
+108 ;; ___(1-3 METs) This METs level has been found to be consistent with
+109 ;; activities such as eating, dressing, taking a shower, slow
+110 ;; walking (2 mph) for 1-2 blocks
+111 ;; ___(>3-5 METs) This METs level has been found to be consistent with
+112 ;; activities such as light yard work (weeding), mowing lawn
+113 ;; (power mower), brisk walking (4 mph)
+114 ;; ___(>5-7 METs) This METs level has been found to be consistent with
+115 ;; activities such as walking 1 flight of stairs, golfing
+116 ;; (without cart), mowing lawn (push mower), heavy yard work
+117 ;; (digging)
+118 ;; ___(>7-10 METs) This METs level has been found to be consistent with
+119 ;; activities such as climbing stairs quickly, moderate
+120 ;; bicycling, sawing wood, jogging (6 mph)
+121 ;; ___ The Veteran denies experiencing symptoms with any level of physical
+122 ;; activity
+123 ;;
+124 ;; c. If the Veteran has had both an exercise stress test and an interview-
+125 ;; based METs test, indicate which results most accurately reflect the
+126 ;; Veteran's current cardiac functional level:
+127 ;; ___ Exercise stress test ___ Interview-based METs test ___ N/A
+128 ;;^TOF^
+129 ;; d. Is the METs level limitation due solely to the heart condition(s)?
+130 ;; ___ Yes ___ No
+131 ;;
+132 ;; If no, estimate the percentage of the METs level limitation that is due
+133 ;; solely to the heart condition(s):
+134 ;; __ 0% __ 10% __ 20% __ 30% __ 40% __ 50% __ 60% __ 70%
+135 ;; __ 80% __ 90%
+136 ;; __ The limitation in METs level is due to multiple factors; it is not
+137 ;; possible to accurately estimate this percentage
+138 ;;
+139 ;; e. In addition to the heart condition(s), does the Veteran have other
+140 ;; non-cardiac medical conditions (such as musculoskeletal or pulmonary
+141 ;; conditions) limiting the METs level?
+142 ;; ___ Yes ___ No
+143 ;;
+144 ;; If yes, identify each condition and describe how each non-cardiac medical
+145 ;; condition limits the Veteran's METs level:
+146 ;; Other medical condition #1: ________ Effect on METs level: ______________
+147 ;; Other medical condition #2: ________ Effect on METs level: ______________
+148 ;; If there are additional medical conditions affecting METs level, list
+149 ;; using above format: _____________________________________________________
+150 ;;
+151 ;; 15. Functional impact
+152 ;;
+153 ;; Does the Veteran's heart condition(s) impact his or her ability to work?
+154 ;; ___ Yes ___ No
+155 ;; If yes, describe impact of each of the Veteran's heart conditions,
+156 ;; providing one or more examples: ____________________________________________
+157 ;;
+158 ;; 16. Remarks, if any: ______________________________________________________
+159 ;;
+160 ;; Physician signature: _____________________________________ Date: ___________
+161 ;;
+162 ;; Physician printed name: ____________________________________________________
+163 ;;
+164 ;; Medical license #: _________________________________________________________
+165 ;;
+166 ;; Physician address: _________________________________________________________
+167 ;;
+168 ;; Phone: _____________________________ FAX: ______________________________
+169 ;;
+170 ;; NOTE: VA may request additional medical information, including additional
+171 ;; examinations if necessary to complete VA's review of the Veteran's
+172 ;; application.
+173 ;;
+174 ;;^END^
+175 QUIT
