DVBCQIH2 ;;ALB-CIOFO/ECF - ISCHEMIC HEART DISEASE (IHD) QUESTIONNAIRE ; 5/10/2010
;;2.7;AMIE;**154**;Apr 10, 1995;Build 7
;
;
;; The Veteran has applied to the U. S. Department of Veterans Affairs for
;; disability benefits. Please complete this Questionnaire, which VA needs for
;; review of the application.
;;
;; 1. Diagnosis
;;
;; Does the Veteran have ischemic heart disease (IHD)? __Yes __No
;;
;; NOTE: Provide only diagnoses that pertain to IHD.
;;
;; Diagnosis #1: __________________________________
;; ICD code: ______________________________________
;; Date of diagnosis #1: __________________________
;;
;; Diagnosis #2: __________________________________
;; ICD code: ______________________________________
;; Date of diagnosis #2: __________________________
;;
;; Diagnosis #3: __________________________________
;; ICD code: ______________________________________
;; Date of diagnosis #3: __________________________
;;
;; If additional diagnoses that pertain to IHD, list using above format:
;;
;; _________________________________________________________________________
;;
;; NOTE: IHD includes, but is not limited to, acute, sub-acute, and old
;; myocardial infarction; atherosclerotic cardiovascular disease including
;; coronary artery disease (including coronary spasm) and coronary bypass
;; surgery; and stable, unstable and Prinzmetal's angina. IHD does not
;; include hypertension or peripheral manifestations of arteriosclerosis such
;; as peripheral vascular disease or stroke, or any other condition that does
;; not qualify within the generally accepted medical definition of ischemic
;; heart disease.
;;^TOF^
;; 2. Medical history
;;
;; Does the Veteran's treatment plan include taking continuous medication for
;; the diagnosed condition?
;;
;; ___Yes ___No
;;
;; List medications: ________________________________________________________
;;
;; Is there a history of:
;;
;; Percutaneous coronary intervention (PCI) ___Yes ___No
;;
;; Treatment facility/date: ___________________________________________
;;
;; Myocardial infarction ___Yes ___No
;;
;; Treatment facility/date:____________________________________________
;;
;; Coronary bypass surgery ___Yes ___No
;;
;; Treatment facility/date:____________________________________________
;;
;; Heart transplant ___Yes ___No
;;
;; Treatment facility/date:____________________________________________
;;
;; If yes, is it as likely as not that the Veteran's heart transplant
;; is due to IHD? ___Yes ___No
;;
;; Implanted cardiac pacemaker ___Yes ___No
;;
;; Treatment facility/date: ___________________________________________
;;
;; If yes, is it as likely as not that the Veteran's pacemaker is
;; due to IHD? ___Yes ___No
;;
;; Implanted automatic implantable cardioverter defibrillator (AICD)
;; ___Yes ___No
;;
;; Treatment facility/date: ___________________________________________
;;
;; If yes, is it as likely as not that the Veteran's AICD is
;; due to IHD? ___Yes ___No
;;^TOF^
;; 3. Congestive heart failure (CHF)
;;
;; Does the Veteran have CHF? ___Yes ___No
;;
;; Is the Veteran's CHF chronic? ___Yes ___No
;;
;; If the Veteran's CHF is not chronic, has the Veteran had more than one
;; episode of acute CHF in the past year? ___Yes ___No
;;
;; Treatment facility/date of most recent episode of CHF: _________________
;;
;; 4. Cardiac functional assessment
;;
;; Has a diagnostic exercise test been conducted? ___Yes ___No
;;
;; a. If yes, provide level of METs the Veteran can perform as shown by
;; the most recent diagnostic exercise testing: __________________________
;;
;; Date of most recent diagnostic exercise test: __________________________
;;
;; b. If exercise METs testing was not completed because it is not required
;; as part of Veteran's treatment plan, complete the following METs test
;; based on the Veteran's responses:
;;
;; Lowest level of activity at which the Veteran reports symptoms
;; (check all symptoms that apply)
;;
;; ___ dyspnea ___ fatigue ___ angina ___ dizziness ___ syncope
;;
;; ___ (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 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 above symptoms with any level of
;; physical activity
;;^TOF^
;; 5. Diagnostic testing
;;
;; Determination of cardiac hypertrophy/dilatation is required; the
;; suggested order of testing for cardiac hypertrophy/dilatation is EKG,
;; then chest x-ray (PA and lateral), then echocardiogram. Echocardiogram
;; is only necessary if the other two tests are negative. A limited
;; echocardiogram, if available, is appropriate to determine if cardiac
;; hypertrophy/dilatation is present by measuring only left ventricular
;; dimension, wall thickness and ejection fraction.
;;
;; Is there evidence of cardiac hypertrophy or dilatation?
;; ___Yes ___No
;;
;; Diagnostic test (provide most recent test only):
;;
;; ___ EKG Date of EKG: _________________________
;;
;; ___ Chest x-ray Date of CXR: _________________________
;;
;; ___ Echocardiogram Date of echocardiogram: ______________
;;
;; ___ Other study (specify):____________ Date: _____________________
;;
;; Left ventricular ejection fraction (LVEF), if known: ____________________%
;;
;; Date of test: _________________________
;;
;; 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.
;;
;; 6. Functional impact
;;
;; Does the Veteran's ischemic heart disease impact his or her ability to
;; work? ___Yes ___No
;;
;; If yes, describe impact, providing one or more examples: _________________
;;
;; __________________________________________________________________________
;;
;;^TOF^
;; 7. Remarks, if any
;;
;; __________________________________________________________________________
;;
;; Physician signature: ________________________________________ Date:__________
;;
;; Physician printed name: _____________________________________ Phone:_________
;;
;; Medical license #: __________________
;;
;; Physician address: __________________________________________________________
;;
;; 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[HDVBCQIH2 8160 printed Apr 09, 2024@20:51:30 Page 2
DVBCQIH2 ;;ALB-CIOFO/ECF - ISCHEMIC HEART DISEASE (IHD) QUESTIONNAIRE ; 5/10/2010
+1 ;;2.7;AMIE;**154**;Apr 10, 1995;Build 7
+2 ;
+3 ;
+4 ;; The Veteran has applied to the U. S. Department of Veterans Affairs for
+5 ;; disability benefits. Please complete this Questionnaire, which VA needs for
+6 ;; review of the application.
+7 ;;
+8 ;; 1. Diagnosis
+9 ;;
+10 ;; Does the Veteran have ischemic heart disease (IHD)? __Yes __No
+11 ;;
+12 ;; NOTE: Provide only diagnoses that pertain to IHD.
+13 ;;
+14 ;; Diagnosis #1: __________________________________
+15 ;; ICD code: ______________________________________
+16 ;; Date of diagnosis #1: __________________________
+17 ;;
+18 ;; Diagnosis #2: __________________________________
+19 ;; ICD code: ______________________________________
+20 ;; Date of diagnosis #2: __________________________
+21 ;;
+22 ;; Diagnosis #3: __________________________________
+23 ;; ICD code: ______________________________________
+24 ;; Date of diagnosis #3: __________________________
+25 ;;
+26 ;; If additional diagnoses that pertain to IHD, list using above format:
+27 ;;
+28 ;; _________________________________________________________________________
+29 ;;
+30 ;; NOTE: IHD includes, but is not limited to, acute, sub-acute, and old
+31 ;; myocardial infarction; atherosclerotic cardiovascular disease including
+32 ;; coronary artery disease (including coronary spasm) and coronary bypass
+33 ;; surgery; and stable, unstable and Prinzmetal's angina. IHD does not
+34 ;; include hypertension or peripheral manifestations of arteriosclerosis such
+35 ;; as peripheral vascular disease or stroke, or any other condition that does
+36 ;; not qualify within the generally accepted medical definition of ischemic
+37 ;; heart disease.
+38 ;;^TOF^
+39 ;; 2. Medical history
+40 ;;
+41 ;; Does the Veteran's treatment plan include taking continuous medication for
+42 ;; the diagnosed condition?
+43 ;;
+44 ;; ___Yes ___No
+45 ;;
+46 ;; List medications: ________________________________________________________
+47 ;;
+48 ;; Is there a history of:
+49 ;;
+50 ;; Percutaneous coronary intervention (PCI) ___Yes ___No
+51 ;;
+52 ;; Treatment facility/date: ___________________________________________
+53 ;;
+54 ;; Myocardial infarction ___Yes ___No
+55 ;;
+56 ;; Treatment facility/date:____________________________________________
+57 ;;
+58 ;; Coronary bypass surgery ___Yes ___No
+59 ;;
+60 ;; Treatment facility/date:____________________________________________
+61 ;;
+62 ;; Heart transplant ___Yes ___No
+63 ;;
+64 ;; Treatment facility/date:____________________________________________
+65 ;;
+66 ;; If yes, is it as likely as not that the Veteran's heart transplant
+67 ;; is due to IHD? ___Yes ___No
+68 ;;
+69 ;; Implanted cardiac pacemaker ___Yes ___No
+70 ;;
+71 ;; Treatment facility/date: ___________________________________________
+72 ;;
+73 ;; If yes, is it as likely as not that the Veteran's pacemaker is
+74 ;; due to IHD? ___Yes ___No
+75 ;;
+76 ;; Implanted automatic implantable cardioverter defibrillator (AICD)
+77 ;; ___Yes ___No
+78 ;;
+79 ;; Treatment facility/date: ___________________________________________
+80 ;;
+81 ;; If yes, is it as likely as not that the Veteran's AICD is
+82 ;; due to IHD? ___Yes ___No
+83 ;;^TOF^
+84 ;; 3. Congestive heart failure (CHF)
+85 ;;
+86 ;; Does the Veteran have CHF? ___Yes ___No
+87 ;;
+88 ;; Is the Veteran's CHF chronic? ___Yes ___No
+89 ;;
+90 ;; If the Veteran's CHF is not chronic, has the Veteran had more than one
+91 ;; episode of acute CHF in the past year? ___Yes ___No
+92 ;;
+93 ;; Treatment facility/date of most recent episode of CHF: _________________
+94 ;;
+95 ;; 4. Cardiac functional assessment
+96 ;;
+97 ;; Has a diagnostic exercise test been conducted? ___Yes ___No
+98 ;;
+99 ;; a. If yes, provide level of METs the Veteran can perform as shown by
+100 ;; the most recent diagnostic exercise testing: __________________________
+101 ;;
+102 ;; Date of most recent diagnostic exercise test: __________________________
+103 ;;
+104 ;; b. If exercise METs testing was not completed because it is not required
+105 ;; as part of Veteran's treatment plan, complete the following METs test
+106 ;; based on the Veteran's responses:
+107 ;;
+108 ;; Lowest level of activity at which the Veteran reports symptoms
+109 ;; (check all symptoms that apply)
+110 ;;
+111 ;; ___ dyspnea ___ fatigue ___ angina ___ dizziness ___ syncope
+112 ;;
+113 ;; ___ (1-3 METs) This METs level has been found to be consistent with
+114 ;; activities such as eating, dressing, taking a shower,
+115 ;; slow walking (2 mph) for 1-2 blocks
+116 ;;
+117 ;; ___ (>3-5 METs) This METs level has been found to be consistent with
+118 ;; activities such as light yard work (weeding), mowing
+119 ;; lawn (power mower), brisk walking (4 mph)
+120 ;;
+121 ;; ___ (>5-7 METs) This METs level has been found to be consistent with
+122 ;; activities such as golfing (without cart), mowing lawn
+123 ;; (push mower), heavy yard work (digging)
+124 ;;
+125 ;; ___ (>7-10 METs) This METs level has been found to be consistent with
+126 ;; activities such as climbing stairs quickly, moderate
+127 ;; bicycling, sawing wood, jogging (6 mph)
+128 ;;
+129 ;; ___ The Veteran denies experiencing above symptoms with any level of
+130 ;; physical activity
+131 ;;^TOF^
+132 ;; 5. Diagnostic testing
+133 ;;
+134 ;; Determination of cardiac hypertrophy/dilatation is required; the
+135 ;; suggested order of testing for cardiac hypertrophy/dilatation is EKG,
+136 ;; then chest x-ray (PA and lateral), then echocardiogram. Echocardiogram
+137 ;; is only necessary if the other two tests are negative. A limited
+138 ;; echocardiogram, if available, is appropriate to determine if cardiac
+139 ;; hypertrophy/dilatation is present by measuring only left ventricular
+140 ;; dimension, wall thickness and ejection fraction.
+141 ;;
+142 ;; Is there evidence of cardiac hypertrophy or dilatation?
+143 ;; ___Yes ___No
+144 ;;
+145 ;; Diagnostic test (provide most recent test only):
+146 ;;
+147 ;; ___ EKG Date of EKG: _________________________
+148 ;;
+149 ;; ___ Chest x-ray Date of CXR: _________________________
+150 ;;
+151 ;; ___ Echocardiogram Date of echocardiogram: ______________
+152 ;;
+153 ;; ___ Other study (specify):____________ Date: _____________________
+154 ;;
+155 ;; Left ventricular ejection fraction (LVEF), if known: ____________________%
+156 ;;
+157 ;; Date of test: _________________________
+158 ;;
+159 ;; If LVEF testing is not of record, but available medical information
+160 ;; sufficiently reflects the severity of the Veteran's cardiovascular
+161 ;; condition, LVEF testing is not required.
+162 ;;
+163 ;; 6. Functional impact
+164 ;;
+165 ;; Does the Veteran's ischemic heart disease impact his or her ability to
+166 ;; work? ___Yes ___No
+167 ;;
+168 ;; If yes, describe impact, providing one or more examples: _________________
+169 ;;
+170 ;; __________________________________________________________________________
+171 ;;
+172 ;;^TOF^
+173 ;; 7. Remarks, if any
+174 ;;
+175 ;; __________________________________________________________________________
+176 ;;
+177 ;; Physician signature: ________________________________________ Date:__________
+178 ;;
+179 ;; Physician printed name: _____________________________________ Phone:_________
+180 ;;
+181 ;; Medical license #: __________________
+182 ;;
+183 ;; Physician address: __________________________________________________________
+184 ;;
+185 ;; NOTE: VA may request additional medical information, including additional
+186 ;; examinations if necessary to complete VA's review of the Veteran's
+187 ;; application.
+188 ;;
+189 ;;
+190 ;; ^END^
+191 QUIT
