DVBCQIH6 ;;ALB-CIOFO/ECF - ISCHEMIC HEART DISEASE (IHD) QUESTIONNAIRE ; 12/21/2010
;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
;
TXT ;
;;
;; Your patient is applying to the U. S. Department of Veterans Affairs
;; (VA) for disability benefits. VA will use the information you provide on
;; this questionnaire to process the Veteran's claim.
;;
;; 1. Diagnosis
;;
;; NOTE: IHD includes, but is not limited to, acute, subacute, 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.
;;
;; 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:
;; _____________________
;;^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
;;
;; 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: _______________________
;;
;; ______________________________________________________________________________
;;^TOF^
;; 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[HDVBCQIH6 7612 printed Apr 09, 2024@20:49:15 Page 2
DVBCQIH6 ;;ALB-CIOFO/ECF - ISCHEMIC HEART DISEASE (IHD) QUESTIONNAIRE ; 12/21/2010
+1 ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will use the information you provide on
+4 ;; this questionnaire to process the Veteran's claim.
+5 ;;
+6 ;; 1. Diagnosis
+7 ;;
+8 ;; NOTE: IHD includes, but is not limited to, acute, subacute, and old
+9 ;; myocardial infarction; atherosclerotic cardiovascular disease including
+10 ;; coronary artery disease (including coronary spasm) and coronary bypass
+11 ;; surgery; and stable, unstable and Prinzmetal's angina. IHD does not include
+12 ;; hypertension or peripheral manifestations of arteriosclerosis such as
+13 ;; peripheral vascular disease or stroke, or any other condition that does not
+14 ;; qualify within the generally accepted medical definition of ischemic heart
+15 ;; disease.
+16 ;; IHD encompasses any atherosclerotic heart disease resulting in clinically
+17 ;; significant ischemia or requiring coronary revascularization.
+18 ;;
+19 ;; Does the Veteran have ischemic heart disease (IHD)? ___ Yes ___ No
+20 ;;
+21 ;; NOTE: Provide only diagnoses that pertain to IHD.
+22 ;; Diagnosis #1: _______________________
+23 ;; ICD code: ___________________________
+24 ;; Date of diagnosis #1: _______________
+25 ;;
+26 ;; Diagnosis #2: _______________________
+27 ;; ICD code: ___________________________
+28 ;; Date of diagnosis #2: _______________
+29 ;;
+30 ;; Diagnosis #3: _______________________
+31 ;; ICD code: ___________________________
+32 ;; Date of diagnosis #3: _______________
+33 ;;
+34 ;; If additional diagnoses that pertain to IHD, list using above format:
+35 ;; _____________________
+36 ;;^TOF^
+37 ;; 2. Medical history
+38 ;;
+39 ;; Does the Veteran's treatment plan include taking continuous medication for
+40 ;; the diagnosed condition? ___ Yes ___ No
+41 ;; List medications: _______________________________________________________
+42 ;;
+43 ;; Is there a history of:
+44 ;;
+45 ;; Percutaneous coronary intervention (PCI) ___ Yes ___ No
+46 ;; Treatment facility/date:_________________________________________________
+47 ;;
+48 ;; Myocardial infarction ___ Yes ___ No
+49 ;; Treatment facility/date:_________________________________________________
+50 ;;
+51 ;; Coronary bypass surgery ___ Yes ___ No
+52 ;; Treatment facility/date:_________________________________________________
+53 ;;
+54 ;; Heart transplant ___ Yes ___ No
+55 ;; Treatment facility/date:_________________________________________________
+56 ;; If yes, is it as likely as not that the Veteran's heart transplant is
+57 ;; due to IHD? ___ Yes ___ No
+58 ;;
+59 ;; Implanted cardiac pacemaker ___ Yes ___ No
+60 ;; Treatment facility/date:_________________________________________________
+61 ;; If yes, is it as likely as not that the Veteran's pacemaker is due to
+62 ;; IHD? ___ Yes ___ No
+63 ;;
+64 ;; Implanted automatic implantable cardioverter defibrillator (AICD)
+65 ;; ___ Yes ___ No
+66 ;; Treatment facility/date: ________________________________________________
+67 ;; If yes, is it as likely as not that the Veteran's AICD is due to IHD?
+68 ;; ___ Yes ___ No
+69 ;;
+70 ;; 3. Congestive heart failure (CHF)
+71 ;;
+72 ;; Does the Veteran have CHF? ___ Yes ___ No
+73 ;; Is the Veteran's CHF chronic? ___ Yes ___ No
+74 ;;
+75 ;; If the Veteran's CHF is not chronic, has the Veteran had more than one
+76 ;; episode of acute CHF in the past year? ___ Yes ___ No
+77 ;;
+78 ;; Treatment facility/date of most recent episode of CHF: _______________________
+79 ;;
+80 ;; ______________________________________________________________________________
+81 ;;^TOF^
+82 ;; 4. Cardiac functional assessment
+83 ;;
+84 ;; Has a diagnostic exercise test been conducted? ___ Yes ___ No
+85 ;;
+86 ;; a. If yes, provide level of METs the Veteran can perform as shown by the
+87 ;; most recent diagnostic exercise testing: _______________
+88 ;;
+89 ;; Date of most recent diagnostic exercise test:___________
+90 ;;
+91 ;; b. If exercise METs testing was not completed because it is not required as
+92 ;; part of Veteran's treatment plan, complete the following METs test based on
+93 ;; the Veteran's responses:
+94 ;;
+95 ;; Lowest level of activity at which the Veteran reports symptoms (check all
+96 ;; symptoms that apply)
+97 ;;
+98 ;; ___ dyspnea ___ fatigue ___ angina ___ dizziness ___ syncope
+99 ;;
+100 ;; ___ (1-3 METs) This METs level has been found to be consistent with
+101 ;; activities such as eating, dressing, taking a shower,
+102 ;; slow walking (2 mph) for 1-2 blocks
+103 ;;
+104 ;; ___ (>3-5 METs) This METs level has been found to be consistent with
+105 ;; activities such as light yard work (weeding), mowing lawn
+106 ;; (power mower), brisk walking (4 mph)
+107 ;;
+108 ;; ___ (>5-7 METs) This METs level has been found to be consistent with
+109 ;; activities such as golfing (without cart), mowing lawn
+110 ;; (push mower), heavy yard work (digging)
+111 ;;
+112 ;; ___ (>7-10 METs) This METs level has been found to be consistent with
+113 ;; activities such as climbing stairs quickly, moderate
+114 ;; bicycling, sawing wood, jogging (6 mph)
+115 ;; ___ The Veteran denies experiencing above symptoms with any level of
+116 ;; physical activity
+117 ;;^TOF^
+118 ;; 5. Diagnostic testing
+119 ;;
+120 ;; Determination of cardiac hypertrophy/dilatation is required; the suggested
+121 ;; order of testing for cardiac hypertrophy/dilatation is EKG, then chest
+122 ;; x-ray (PA and lateral), then echocardiogram. Echocardiogram is only
+123 ;; necessary if the other two tests are negative. A limited echocardiogram, if
+124 ;; available, is appropriate to determine if cardiac hypertrophy/dilatation is
+125 ;; present by measuring only left ventricular dimension, wall thickness and
+126 ;; ejection fraction.
+127 ;;
+128 ;; Is there evidence of cardiac hypertrophy or dilatation?
+129 ;; ___ Yes ___ No
+130 ;;
+131 ;; Diagnostic test (provide most recent test only):
+132 ;;
+133 ;; ___ EKG Date of EKG: ______________
+134 ;; ___ Chest x-ray Date of CXR: ______________
+135 ;; ___ Echocardiogram Date of echocardiogram:_______________
+136 ;; ___ Other study (specify): ________ Date:_______________
+137 ;;
+138 ;; Left ventricular ejection fraction (LVEF), if known: ______%
+139 ;; Date of test: ________________
+140 ;;
+141 ;; If LVEF testing is not of record, but available medical information
+142 ;; sufficiently reflects the severity of the Veteran's cardiovascular condition,
+143 ;; LVEF testing is not required.
+144 ;;
+145 ;; 6. Functional impact
+146 ;; Does the Veteran's ischemic heart disease impact his or her ability to work?
+147 ;; ___ Yes ___ No
+148 ;;
+149 ;; If yes, describe impact, providing one or more examples: ____________________
+150 ;;
+151 ;; _____________________________________________________________________________
+152 ;;^TOF^
+153 ;; 7. Remarks, if any
+154 ;;
+155 ;; ____________________________________________________________________________
+156 ;;
+157 ;; Physician signature: ________________________________________ Date:__________
+158 ;;
+159 ;; Physician printed name: _____________________________________ Phone:_________
+160 ;;
+161 ;; Medical license #: __________________
+162 ;;
+163 ;; Physician address: __________________________________________________________
+164 ;;
+165 ;; NOTE: VA may request additional medical information, including additional
+166 ;; examinations if necessary to complete VA's review of the Veteran's
+167 ;; application.
+168 ;;
+169 ;; ^END^
+170 QUIT
