DVBCQHT2 ;;ALB-CIOFO/ECF - HYPERTENSION 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
;; hypertension or isolated systolic hypertension based on the following
;; criteria:
;;
;; NOTE 1: For VA disability rating purposes, the term hypertension means
;; that the diastolic blood pressure is predominantly 90mm or greater, and
;; isolated systolic hypertension means that the systolic blood pressure is
;; predominantly 160mm or greater with a diastolic blood pressure of less
;; than 90mm.
;;
;; NOTE 2: For VA purposes, for the INITIAL diagnosis of hypertension or
;; isolated systolic hypertension must be confirmed by readings taken 2 or
;; more times on at least 3 different days. Blood pressure results may be
;; obtained from existing medical records or through scheduled visits for
;; blood pressure measurements.
;;
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to hypertension:
;;
;; ___Hypertension ICD code: __________ Date of diagnosis: _______
;; ___Isolated systolic hypertension
;; ICD code: ___________ Date of diagnosis: _______
;; ___Other, specify:
;; Other diagnosis #1: ____________________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; Other diagnosis #2: ____________________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; If there are additional diagnoses that pertain to hypertension or isolated
;; systolic hypertension, list using above format: ____________________________
;;
;; ____________________________________________________________________________
;;
;; NOTE 3: ALSO complete appropriate questionnaires for hypertension-related
;; complications, if any (such as Kidney, if renal insufficiency attributable
;; to hypertension ).
;;^TOF^
;; 2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's
;; hypertension condition (brief summary):
;; ____________________________________________________________________________
;;
;; b. Does the Veteran's treatment plan include taking continuous medication
;; for hypertension or isolated systolic hypertension?
;; ___ Yes ___ No
;; If yes, list only those medications used for the diagnosed conditions:
;; ____________________________________________________________________________
;;
;;
;; c. Was the Veteran's initial diagnosis of hypertension or isolated systolic
;; hypertension confirmed by blood pressure (BP) readings taken 2 or more times
;; on at least 3 different days?
;;
;; ___ Yes ___ No ___ Unknown
;;
;; If yes, provide any BP readings used to establish initial diagnosis, if
;; known:
;;
;; Reading 1: ______/______ Reading 2: ______/______ Date: __________
;; Reading 1: ______/______ Reading 2: ______/______ Date: __________
;; Reading 1: ______/______ Reading 2: ______/______ Date: __________
;;
;; If no, report BP readings taken 2 or more times on at least 3 different
;; days in order to confirm diagnosis (unless veteran is on treatment for
;; hypertension).
;;
;; Reading 1: ______/______ Reading 2: ______/______ Date: __________
;; Reading 1: ______/______ Reading 2: ______/______ Date: __________
;; Reading 1: ______/______ Reading 2: ______/______ Date: __________
;;
;; d. Does the Veteran have a history of a diastolic BP elevation to
;; predominantly 100 or more?
;; ___ Yes ___ No
;; If yes, describe frequency and severity of diastolic BP elevation:
;; ____________________________________________________________________________
;;
;;^TOF^
;; 3. Current blood pressure readings (sufficient if Veteran has a
;; previously established diagnosis of hypertension).
;;
;; Blood pressure reading 1: ______/______ Date: __________
;; Blood pressure reading 2: ______/______ Date: __________
;; Blood pressure reading 3: ______/______ Date: __________
;;
;; 4. 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 39 square cm (6 square inches) or greater?
;; ___ Yes ___ No
;; If yes, also complete a Scars Questionnaire.
;;
;; b. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs or symptoms related to the condition listed
;; in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): __________________________________________
;;^TOF^
;; 5. Functional impact
;;
;; Does the Veteran's hypertension or isolated systolic hypertension impact his
;; or her ability to work?
;; ___ Yes ___ No
;;
;; If yes, describe the impact of the Veteran's hypertension or isolated
;; systolic hypertension, providing one or more examples ______________________
;;
;; ____________________________________________________________________________
;;
;; 6. 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[HDVBCQHT2 6564 printed Apr 09, 2024@20:46:20 Page 2
DVBCQHT2 ;;ALB-CIOFO/ECF - HYPERTENSION 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
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;;
+8 ;; 1. Diagnosis
+9 ;;
+10 ;; Does the Veteran now have or has he/she ever been diagnosed with
+11 ;; hypertension or isolated systolic hypertension based on the following
+12 ;; criteria:
+13 ;;
+14 ;; NOTE 1: For VA disability rating purposes, the term hypertension means
+15 ;; that the diastolic blood pressure is predominantly 90mm or greater, and
+16 ;; isolated systolic hypertension means that the systolic blood pressure is
+17 ;; predominantly 160mm or greater with a diastolic blood pressure of less
+18 ;; than 90mm.
+19 ;;
+20 ;; NOTE 2: For VA purposes, for the INITIAL diagnosis of hypertension or
+21 ;; isolated systolic hypertension must be confirmed by readings taken 2 or
+22 ;; more times on at least 3 different days. Blood pressure results may be
+23 ;; obtained from existing medical records or through scheduled visits for
+24 ;; blood pressure measurements.
+25 ;;
+26 ;; ___ Yes ___ No
+27 ;;
+28 ;; If yes, provide only diagnoses that pertain to hypertension:
+29 ;;
+30 ;; ___Hypertension ICD code: __________ Date of diagnosis: _______
+31 ;; ___Isolated systolic hypertension
+32 ;; ICD code: ___________ Date of diagnosis: _______
+33 ;; ___Other, specify:
+34 ;; Other diagnosis #1: ____________________
+35 ;; ICD code: ________________________
+36 ;; Date of diagnosis: _______________
+37 ;;
+38 ;; Other diagnosis #2: ____________________
+39 ;; ICD code: ________________________
+40 ;; Date of diagnosis: _______________
+41 ;;
+42 ;; If there are additional diagnoses that pertain to hypertension or isolated
+43 ;; systolic hypertension, list using above format: ____________________________
+44 ;;
+45 ;; ____________________________________________________________________________
+46 ;;
+47 ;; NOTE 3: ALSO complete appropriate questionnaires for hypertension-related
+48 ;; complications, if any (such as Kidney, if renal insufficiency attributable
+49 ;; to hypertension ).
+50 ;;^TOF^
+51 ;; 2. Medical history
+52 ;;
+53 ;; a. Describe the history (including onset and course) of the Veteran's
+54 ;; hypertension condition (brief summary):
+55 ;; ____________________________________________________________________________
+56 ;;
+57 ;; b. Does the Veteran's treatment plan include taking continuous medication
+58 ;; for hypertension or isolated systolic hypertension?
+59 ;; ___ Yes ___ No
+60 ;; If yes, list only those medications used for the diagnosed conditions:
+61 ;; ____________________________________________________________________________
+62 ;;
+63 ;;
+64 ;; c. Was the Veteran's initial diagnosis of hypertension or isolated systolic
+65 ;; hypertension confirmed by blood pressure (BP) readings taken 2 or more times
+66 ;; on at least 3 different days?
+67 ;;
+68 ;; ___ Yes ___ No ___ Unknown
+69 ;;
+70 ;; If yes, provide any BP readings used to establish initial diagnosis, if
+71 ;; known:
+72 ;;
+73 ;; Reading 1: ______/______ Reading 2: ______/______ Date: __________
+74 ;; Reading 1: ______/______ Reading 2: ______/______ Date: __________
+75 ;; Reading 1: ______/______ Reading 2: ______/______ Date: __________
+76 ;;
+77 ;; If no, report BP readings taken 2 or more times on at least 3 different
+78 ;; days in order to confirm diagnosis (unless veteran is on treatment for
+79 ;; hypertension).
+80 ;;
+81 ;; Reading 1: ______/______ Reading 2: ______/______ Date: __________
+82 ;; Reading 1: ______/______ Reading 2: ______/______ Date: __________
+83 ;; Reading 1: ______/______ Reading 2: ______/______ Date: __________
+84 ;;
+85 ;; d. Does the Veteran have a history of a diastolic BP elevation to
+86 ;; predominantly 100 or more?
+87 ;; ___ Yes ___ No
+88 ;; If yes, describe frequency and severity of diastolic BP elevation:
+89 ;; ____________________________________________________________________________
+90 ;;
+91 ;;^TOF^
+92 ;; 3. Current blood pressure readings (sufficient if Veteran has a
+93 ;; previously established diagnosis of hypertension).
+94 ;;
+95 ;; Blood pressure reading 1: ______/______ Date: __________
+96 ;; Blood pressure reading 2: ______/______ Date: __________
+97 ;; Blood pressure reading 3: ______/______ Date: __________
+98 ;;
+99 ;; 4. Other pertinent physical findings, complications, conditions, signs
+100 ;; and/or symptoms
+101 ;;
+102 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+103 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+104 ;; section above?
+105 ;; ___ Yes ___ No
+106 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+107 ;; of all related scars 39 square cm (6 square inches) or greater?
+108 ;; ___ Yes ___ No
+109 ;; If yes, also complete a Scars Questionnaire.
+110 ;;
+111 ;; b. Does the Veteran have any other pertinent physical findings,
+112 ;; complications, conditions, signs or symptoms related to the condition listed
+113 ;; in the Diagnosis section above?
+114 ;; ___ Yes ___ No
+115 ;; If yes, describe (brief summary): __________________________________________
+116 ;;^TOF^
+117 ;; 5. Functional impact
+118 ;;
+119 ;; Does the Veteran's hypertension or isolated systolic hypertension impact his
+120 ;; or her ability to work?
+121 ;; ___ Yes ___ No
+122 ;;
+123 ;; If yes, describe the impact of the Veteran's hypertension or isolated
+124 ;; systolic hypertension, providing one or more examples ______________________
+125 ;;
+126 ;; ____________________________________________________________________________
+127 ;;
+128 ;; 6. Remarks, if any: ________________________________________________________
+129 ;;
+130 ;; ____________________________________________________________________________
+131 ;;
+132 ;; Physician signature: _____________________________________ Date: ___________
+133 ;;
+134 ;; Physician printed name: ____________________________________________________
+135 ;;
+136 ;; Medical license #: _________________________________________________________
+137 ;;
+138 ;; Physician address: _________________________________________________________
+139 ;;
+140 ;; Phone: _____________________________ FAX: ______________________________
+141 ;;
+142 ;; NOTE: VA may request additional medical information, including additional
+143 ;; examinations if necessary to complete VA's review of the Veteran's
+144 ;; application.
+145 ;;
+146 ;;^END^
+147 QUIT
