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Routine: DVBCQHT2

DVBCQHT2.m

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  1. DVBCQHT2 ;;ALB-CIOFO/ECF - HYPERTENSION 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
  1.  ;; (VA) for disability benefits.  VA will consider the information you
  1.  ;; provide on this questionnaire as part of their evaluation in processing
  1.  ;; the Veteran's claim.
  1.  ;;
  1.  ;;
  1.  ;; 1. Diagnosis 
  1.  ;;
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with
  1.  ;; hypertension or isolated systolic hypertension based on the following
  1.  ;; criteria:
  1.  ;;
  1.  ;;    NOTE 1: For VA disability rating purposes, the term hypertension means
  1.  ;;    that the diastolic blood pressure is predominantly 90mm or greater, and
  1.  ;;    isolated systolic hypertension means that the systolic blood pressure is
  1.  ;;    predominantly 160mm or greater with a diastolic blood pressure of less
  1.  ;;    than 90mm.
  1.  ;;
  1.  ;;    NOTE 2: For VA purposes, for the INITIAL diagnosis of hypertension or
  1.  ;;    isolated systolic hypertension must be confirmed by readings taken 2 or
  1.  ;;    more times on at least 3 different days. Blood pressure results may be
  1.  ;;    obtained from existing medical records or through scheduled visits for
  1.  ;;    blood pressure measurements.
  1.  ;;
  1.  ;; ___ Yes  ___ No
  1.  ;;
  1.  ;; If yes, provide only diagnoses that pertain to hypertension:
  1.  ;;
  1.  ;; ___Hypertension            ICD code: __________  Date of diagnosis: _______
  1.  ;; ___Isolated systolic hypertension
  1.  ;;                            ICD code: ___________ Date of diagnosis: _______
  1.  ;; ___Other, specify: 
  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 hypertension or isolated
  1.  ;; systolic hypertension, list using above format: ____________________________
  1.  ;;
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; NOTE 3: ALSO complete appropriate questionnaires for hypertension-related
  1.  ;; complications, if any (such as Kidney, if renal insufficiency attributable
  1.  ;; to hypertension ).
  1.  ;;^TOF^
  1.  ;; 2. Medical history
  1.  ;;
  1.  ;; a. Describe the history (including onset and course) of the Veteran's
  1.  ;; hypertension condition (brief summary): 
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; b. Does the Veteran's treatment plan include taking continuous medication
  1.  ;; for hypertension or isolated systolic hypertension?
  1.  ;; ___ Yes  ___ No   
  1.  ;; If yes, list only those medications used for the diagnosed conditions:
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;;
  1.  ;; c. Was the Veteran's initial diagnosis of hypertension or isolated systolic
  1.  ;; hypertension confirmed by blood pressure (BP) readings taken 2 or more times
  1.  ;; on at least 3 different days?
  1.  ;;
  1.  ;; ___ Yes ___ No  ___ Unknown
  1.  ;;
  1.  ;; If yes, provide any BP readings used to establish initial diagnosis, if
  1.  ;; known:
  1.  ;;
  1.  ;;    Reading 1: ______/______   Reading 2: ______/______   Date: __________
  1.  ;;    Reading 1: ______/______   Reading 2: ______/______   Date: __________
  1.  ;;    Reading 1: ______/______   Reading 2: ______/______   Date: __________
  1.  ;;
  1.  ;; If no, report BP readings taken 2 or more times on at least 3 different
  1.  ;; days in order to confirm diagnosis (unless veteran is on treatment for
  1.  ;; hypertension).
  1.  ;;
  1.  ;;    Reading 1: ______/______   Reading 2: ______/______   Date: __________
  1.  ;;    Reading 1: ______/______   Reading 2: ______/______   Date: __________
  1.  ;;    Reading 1: ______/______   Reading 2: ______/______   Date: __________
  1.  ;;
  1.  ;; d. Does the Veteran have a history of a diastolic BP elevation to 
  1.  ;; predominantly 100 or more?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe frequency and severity of diastolic BP elevation:
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;;^TOF^
  1.  ;; 3. Current blood pressure readings (sufficient if Veteran has a
  1.  ;; previously established diagnosis of hypertension).
  1.  ;;
  1.  ;; Blood pressure reading 1: ______/______   Date: __________
  1.  ;; Blood pressure reading 2: ______/______   Date: __________
  1.  ;; Blood pressure reading 3: ______/______   Date: __________
  1.  ;;
  1.  ;; 4. 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 39 square cm (6 square inches) or greater?
  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 or symptoms related to the condition listed
  1.  ;; in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): __________________________________________
  1.  ;;^TOF^
  1.  ;; 5. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's hypertension or isolated systolic hypertension impact his
  1.  ;; or her ability to work?
  1.  ;; ___ Yes  ___ No
  1.  ;;
  1.  ;; If yes, describe the impact of the Veteran's hypertension or isolated
  1.  ;; systolic hypertension, providing one or more examples ______________________
  1.  ;;
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 6. Remarks, if any: ________________________________________________________
  1.  ;;
  1.  ;; ____________________________________________________________________________
  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