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Routine: DVBCQIH4

DVBCQIH4.m

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DVBCQIH4 ;;ALB-CIOFO/ECF - ISCHEMIC HEART DISEASE (IHD) QUESTIONNAIRE ; 5/10/2010
 ;;2.7;AMIE;**159**;Apr 10, 1995;Build 5
 ;
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 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.
 ;;
 ;;    IHD encompasses any atherosclerotic heart disease resulting in clinically
 ;;    significant ischemia or requiring coronary revascularization.
 ;;^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