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Routine: DVBCQIH4

DVBCQIH4.m

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  1. DVBCQIH4 ;;ALB-CIOFO/ECF - ISCHEMIC HEART DISEASE (IHD) QUESTIONNAIRE ; 5/10/2010
  1.  ;;2.7;AMIE;**159**;Apr 10, 1995;Build 5
  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. Diagnosis
  1.  ;;
  1.  ;;    Does the Veteran have ischemic heart disease (IHD)?      __Yes __No
  1.  ;;
  1.  ;;    NOTE: Provide only diagnoses that pertain to IHD.
  1.  ;;
  1.  ;;    Diagnosis #1: __________________________________  
  1.  ;;    ICD code: ______________________________________
  1.  ;;    Date of diagnosis #1: __________________________
  1.  ;;
  1.  ;;    Diagnosis #2: __________________________________  
  1.  ;;    ICD code: ______________________________________
  1.  ;;    Date of diagnosis #2: __________________________
  1.  ;;
  1.  ;;    Diagnosis #3: __________________________________  
  1.  ;;    ICD code: ______________________________________
  1.  ;;    Date of diagnosis #3: __________________________
  1.  ;; 
  1.  ;;    If additional diagnoses that pertain to IHD, list using above format: 
  1.  ;;
  1.  ;;    _________________________________________________________________________
  1.  ;;
  1.  ;;    NOTE: IHD includes, but is not limited to, acute, sub-acute, and old 
  1.  ;;    myocardial infarction; atherosclerotic cardiovascular disease including
  1.  ;;    coronary artery disease (including coronary spasm) and coronary bypass
  1.  ;;    surgery; and stable, unstable and Prinzmetal's angina. IHD does not
  1.  ;;    include hypertension or peripheral manifestations of arteriosclerosis such
  1.  ;;    as peripheral vascular disease or stroke, or any other condition that does
  1.  ;;    not qualify within the generally accepted medical definition of ischemic
  1.  ;;    heart disease.
  1.  ;;
  1.  ;;    IHD encompasses any atherosclerotic heart disease resulting in clinically
  1.  ;;    significant ischemia or requiring coronary revascularization.
  1.  ;;^TOF^
  1.  ;; 2. Medical history
  1.  ;;
  1.  ;;    Does the Veteran's treatment plan include taking continuous medication for
  1.  ;;    the diagnosed condition? 
  1.  ;;
  1.  ;;    ___Yes  ___No  
  1.  ;;
  1.  ;;    List medications: ________________________________________________________   
  1.  ;;
  1.  ;;   Is there a history of:
  1.  ;;
  1.  ;;      Percutaneous coronary intervention (PCI)    ___Yes    ___No
  1.  ;;    
  1.  ;;          Treatment facility/date: ___________________________________________
  1.  ;;
  1.  ;;      Myocardial infarction        ___Yes     ___No 
  1.  ;;
  1.  ;;          Treatment facility/date:____________________________________________
  1.  ;;
  1.  ;;      Coronary bypass surgery      ___Yes     ___No 
  1.  ;;
  1.  ;;          Treatment facility/date:____________________________________________
  1.  ;;
  1.  ;;      Heart transplant             ___Yes     ___No 
  1.  ;;
  1.  ;;          Treatment facility/date:____________________________________________
  1.  ;;
  1.  ;;          If yes, is it as likely as not that the Veteran's heart transplant
  1.  ;;          is due to IHD?             ___Yes   ___No
  1.  ;;
  1.  ;;      Implanted cardiac pacemaker    ___Yes     ___No
  1.  ;;
  1.  ;;          Treatment facility/date: ___________________________________________
  1.  ;;
  1.  ;;          If yes, is it as likely as not that the Veteran's pacemaker is
  1.  ;;          due to IHD? ___Yes    ___No 
  1.  ;;
  1.  ;;      Implanted automatic implantable cardioverter defibrillator (AICD)
  1.  ;;          ___Yes      ___No
  1.  ;;
  1.  ;;          Treatment facility/date: ___________________________________________
  1.  ;;
  1.  ;;          If yes, is it as likely as not that the Veteran's AICD is
  1.  ;;          due to IHD? ___Yes    ___No
  1.  ;;^TOF^
  1.  ;; 3. Congestive heart failure (CHF)
  1.  ;;
  1.  ;;    Does the Veteran have CHF?        ___Yes     ___No
  1.  ;;
  1.  ;;    Is the Veteran's CHF chronic?     ___Yes     ___No
  1.  ;;
  1.  ;;    If the Veteran's CHF is not chronic, has the Veteran had more than one 
  1.  ;;    episode of acute CHF in the past year?   ___Yes    ___No
  1.  ;;
  1.  ;;      Treatment facility/date of most recent episode of CHF: _________________
  1.  ;;
  1.  ;; 4. Cardiac functional assessment
  1.  ;;
  1.  ;;    Has a diagnostic exercise test been conducted?  ___Yes    ___No 
  1.  ;;
  1.  ;;      a. If yes, provide level of METs the Veteran can perform as shown by 
  1.  ;;      the most recent diagnostic exercise testing:  __________________________
  1.  ;;
  1.  ;;      Date of most recent diagnostic exercise test: __________________________
  1.  ;;
  1.  ;;      b. If exercise METs testing was not completed because it is not required
  1.  ;;      as part of Veteran's treatment plan, complete the following METs test 
  1.  ;;      based on the Veteran's responses:
  1.  ;;
  1.  ;;      Lowest level of activity at which the Veteran reports symptoms
  1.  ;;      (check all symptoms that apply)
  1.  ;;
  1.  ;;         ___ dyspnea   ___ fatigue   ___ angina   ___ dizziness   ___ syncope
  1.  ;;
  1.  ;;      ___ (1-3 METs)   This METs level has been found to be consistent with
  1.  ;;                       activities such as eating, dressing, taking a shower, 
  1.  ;;                       slow walking (2 mph) for 1-2 blocks
  1.  ;;
  1.  ;;      ___ (>3-5 METs)  This METs level has been found to be consistent with 
  1.  ;;                       activities such as light yard work (weeding), mowing
  1.  ;;                       lawn (power mower), brisk walking (4 mph)
  1.  ;;
  1.  ;;      ___ (>5-7 METs)  This METs level has been found to be consistent with
  1.  ;;                       activities such as golfing (without cart), mowing lawn
  1.  ;;                       (push mower), heavy yard work (digging)
  1.  ;;
  1.  ;;      ___ (>7-10 METs) This METs level has been found to be consistent with
  1.  ;;                       activities such as climbing stairs quickly, moderate
  1.  ;;                       bicycling, sawing wood, jogging (6 mph)
  1.  ;;
  1.  ;;      ___ The Veteran denies experiencing above symptoms with any level of
  1.  ;;          physical activity
  1.  ;;^TOF^
  1.  ;; 5. Diagnostic testing
  1.  ;;
  1.  ;;      Determination of cardiac hypertrophy/dilatation is required; the
  1.  ;;      suggested order of testing for cardiac hypertrophy/dilatation is EKG,
  1.  ;;      then chest x-ray (PA and lateral), then echocardiogram.  Echocardiogram
  1.  ;;      is only necessary if the other two tests are negative.  A limited 
  1.  ;;      echocardiogram, if available, is appropriate to determine if cardiac
  1.  ;;      hypertrophy/dilatation is present by measuring only left ventricular
  1.  ;;      dimension, wall thickness and ejection fraction.
  1.  ;;
  1.  ;;    Is there evidence of cardiac hypertrophy or dilatation?
  1.  ;;             ___Yes   ___No
  1.  ;;
  1.  ;;    Diagnostic test (provide most recent test only):
  1.  ;;
  1.  ;;           ___ EKG                      Date of EKG: _________________________
  1.  ;;
  1.  ;;           ___ Chest x-ray              Date of CXR: _________________________
  1.  ;;
  1.  ;;           ___ Echocardiogram           Date of echocardiogram: ______________
  1.  ;;
  1.  ;;           ___ Other study (specify):____________  Date: _____________________
  1.  ;;
  1.  ;;    Left ventricular ejection fraction (LVEF), if known: ____________________%
  1.  ;;
  1.  ;;       Date of test: _________________________
  1.  ;;
  1.  ;;          If LVEF testing is not of record, but available medical information
  1.  ;;          sufficiently reflects the severity of the Veteran's cardiovascular
  1.  ;;          condition, LVEF testing is not required.
  1.  ;;
  1.  ;; 6. Functional impact
  1.  ;;
  1.  ;;    Does the Veteran's ischemic heart disease impact his or her ability to
  1.  ;;    work?   ___Yes   ___No
  1.  ;;
  1.  ;;    If yes, describe impact, providing one or more examples: _________________
  1.  ;;
  1.  ;;    __________________________________________________________________________
  1.  ;;
  1.  ;;^TOF^
  1.  ;; 7. Remarks, if any
  1.  ;;
  1.  ;;    __________________________________________________________________________
  1.  ;;
  1.  ;; Physician signature: ________________________________________ Date:__________
  1.  ;; 
  1.  ;; Physician printed name: _____________________________________ Phone:_________
  1.  ;; 
  1.  ;; Medical license #: __________________
  1.  ;; 
  1.  ;; Physician address: __________________________________________________________
  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.  ;;                              
  1.  ;; ^END^
  1.  Q