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
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQIH4 8384 printed Nov 22, 2024@16:57:01 Page 2
DVBCQIH4 ;;ALB-CIOFO/ECF - ISCHEMIC HEART DISEASE (IHD) QUESTIONNAIRE ; 5/10/2010
+1 ;;2.7;AMIE;**159**;Apr 10, 1995;Build 5
+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 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran have ischemic heart disease (IHD)? __Yes __No
+10 ;;
+11 ;; NOTE: Provide only diagnoses that pertain to IHD.
+12 ;;
+13 ;; Diagnosis #1: __________________________________
+14 ;; ICD code: ______________________________________
+15 ;; Date of diagnosis #1: __________________________
+16 ;;
+17 ;; Diagnosis #2: __________________________________
+18 ;; ICD code: ______________________________________
+19 ;; Date of diagnosis #2: __________________________
+20 ;;
+21 ;; Diagnosis #3: __________________________________
+22 ;; ICD code: ______________________________________
+23 ;; Date of diagnosis #3: __________________________
+24 ;;
+25 ;; If additional diagnoses that pertain to IHD, list using above format:
+26 ;;
+27 ;; _________________________________________________________________________
+28 ;;
+29 ;; NOTE: IHD includes, but is not limited to, acute, sub-acute, and old
+30 ;; myocardial infarction; atherosclerotic cardiovascular disease including
+31 ;; coronary artery disease (including coronary spasm) and coronary bypass
+32 ;; surgery; and stable, unstable and Prinzmetal's angina. IHD does not
+33 ;; include hypertension or peripheral manifestations of arteriosclerosis such
+34 ;; as peripheral vascular disease or stroke, or any other condition that does
+35 ;; not qualify within the generally accepted medical definition of ischemic
+36 ;; heart disease.
+37 ;;
+38 ;; IHD encompasses any atherosclerotic heart disease resulting in clinically
+39 ;; significant ischemia or requiring coronary revascularization.
+40 ;;^TOF^
+41 ;; 2. Medical history
+42 ;;
+43 ;; Does the Veteran's treatment plan include taking continuous medication for
+44 ;; the diagnosed condition?
+45 ;;
+46 ;; ___Yes ___No
+47 ;;
+48 ;; List medications: ________________________________________________________
+49 ;;
+50 ;; Is there a history of:
+51 ;;
+52 ;; Percutaneous coronary intervention (PCI) ___Yes ___No
+53 ;;
+54 ;; Treatment facility/date: ___________________________________________
+55 ;;
+56 ;; Myocardial infarction ___Yes ___No
+57 ;;
+58 ;; Treatment facility/date:____________________________________________
+59 ;;
+60 ;; Coronary bypass surgery ___Yes ___No
+61 ;;
+62 ;; Treatment facility/date:____________________________________________
+63 ;;
+64 ;; Heart transplant ___Yes ___No
+65 ;;
+66 ;; Treatment facility/date:____________________________________________
+67 ;;
+68 ;; If yes, is it as likely as not that the Veteran's heart transplant
+69 ;; is due to IHD? ___Yes ___No
+70 ;;
+71 ;; Implanted cardiac pacemaker ___Yes ___No
+72 ;;
+73 ;; Treatment facility/date: ___________________________________________
+74 ;;
+75 ;; If yes, is it as likely as not that the Veteran's pacemaker is
+76 ;; due to IHD? ___Yes ___No
+77 ;;
+78 ;; Implanted automatic implantable cardioverter defibrillator (AICD)
+79 ;; ___Yes ___No
+80 ;;
+81 ;; Treatment facility/date: ___________________________________________
+82 ;;
+83 ;; If yes, is it as likely as not that the Veteran's AICD is
+84 ;; due to IHD? ___Yes ___No
+85 ;;^TOF^
+86 ;; 3. Congestive heart failure (CHF)
+87 ;;
+88 ;; Does the Veteran have CHF? ___Yes ___No
+89 ;;
+90 ;; Is the Veteran's CHF chronic? ___Yes ___No
+91 ;;
+92 ;; If the Veteran's CHF is not chronic, has the Veteran had more than one
+93 ;; episode of acute CHF in the past year? ___Yes ___No
+94 ;;
+95 ;; Treatment facility/date of most recent episode of CHF: _________________
+96 ;;
+97 ;; 4. Cardiac functional assessment
+98 ;;
+99 ;; Has a diagnostic exercise test been conducted? ___Yes ___No
+100 ;;
+101 ;; a. If yes, provide level of METs the Veteran can perform as shown by
+102 ;; the most recent diagnostic exercise testing: __________________________
+103 ;;
+104 ;; Date of most recent diagnostic exercise test: __________________________
+105 ;;
+106 ;; b. If exercise METs testing was not completed because it is not required
+107 ;; as part of Veteran's treatment plan, complete the following METs test
+108 ;; based on the Veteran's responses:
+109 ;;
+110 ;; Lowest level of activity at which the Veteran reports symptoms
+111 ;; (check all symptoms that apply)
+112 ;;
+113 ;; ___ dyspnea ___ fatigue ___ angina ___ dizziness ___ syncope
+114 ;;
+115 ;; ___ (1-3 METs) This METs level has been found to be consistent with
+116 ;; activities such as eating, dressing, taking a shower,
+117 ;; slow walking (2 mph) for 1-2 blocks
+118 ;;
+119 ;; ___ (>3-5 METs) This METs level has been found to be consistent with
+120 ;; activities such as light yard work (weeding), mowing
+121 ;; lawn (power mower), brisk walking (4 mph)
+122 ;;
+123 ;; ___ (>5-7 METs) This METs level has been found to be consistent with
+124 ;; activities such as golfing (without cart), mowing lawn
+125 ;; (push mower), heavy yard work (digging)
+126 ;;
+127 ;; ___ (>7-10 METs) This METs level has been found to be consistent with
+128 ;; activities such as climbing stairs quickly, moderate
+129 ;; bicycling, sawing wood, jogging (6 mph)
+130 ;;
+131 ;; ___ The Veteran denies experiencing above symptoms with any level of
+132 ;; physical activity
+133 ;;^TOF^
+134 ;; 5. Diagnostic testing
+135 ;;
+136 ;; Determination of cardiac hypertrophy/dilatation is required; the
+137 ;; suggested order of testing for cardiac hypertrophy/dilatation is EKG,
+138 ;; then chest x-ray (PA and lateral), then echocardiogram. Echocardiogram
+139 ;; is only necessary if the other two tests are negative. A limited
+140 ;; echocardiogram, if available, is appropriate to determine if cardiac
+141 ;; hypertrophy/dilatation is present by measuring only left ventricular
+142 ;; dimension, wall thickness and ejection fraction.
+143 ;;
+144 ;; Is there evidence of cardiac hypertrophy or dilatation?
+145 ;; ___Yes ___No
+146 ;;
+147 ;; Diagnostic test (provide most recent test only):
+148 ;;
+149 ;; ___ EKG Date of EKG: _________________________
+150 ;;
+151 ;; ___ Chest x-ray Date of CXR: _________________________
+152 ;;
+153 ;; ___ Echocardiogram Date of echocardiogram: ______________
+154 ;;
+155 ;; ___ Other study (specify):____________ Date: _____________________
+156 ;;
+157 ;; Left ventricular ejection fraction (LVEF), if known: ____________________%
+158 ;;
+159 ;; Date of test: _________________________
+160 ;;
+161 ;; If LVEF testing is not of record, but available medical information
+162 ;; sufficiently reflects the severity of the Veteran's cardiovascular
+163 ;; condition, LVEF testing is not required.
+164 ;;
+165 ;; 6. Functional impact
+166 ;;
+167 ;; Does the Veteran's ischemic heart disease impact his or her ability to
+168 ;; work? ___Yes ___No
+169 ;;
+170 ;; If yes, describe impact, providing one or more examples: _________________
+171 ;;
+172 ;; __________________________________________________________________________
+173 ;;
+174 ;;^TOF^
+175 ;; 7. Remarks, if any
+176 ;;
+177 ;; __________________________________________________________________________
+178 ;;
+179 ;; Physician signature: ________________________________________ Date:__________
+180 ;;
+181 ;; Physician printed name: _____________________________________ Phone:_________
+182 ;;
+183 ;; Medical license #: __________________
+184 ;;
+185 ;; Physician address: __________________________________________________________
+186 ;;
+187 ;; NOTE: VA may request additional medical information, including additional
+188 ;; examinations if necessary to complete VA's review of the Veteran's
+189 ;; application.
+190 ;;
+191 ;;
+192 ;; ^END^
+193 QUIT
