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Routine: DVBCQIH6

DVBCQIH6.m

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  1. DVBCQIH6 ;;ALB-CIOFO/ECF - ISCHEMIC HEART DISEASE (IHD) QUESTIONNAIRE ; 12/21/2010
  1.  ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs
  1.  ;; (VA) for disability benefits.  VA will use the information you provide on
  1.  ;; this questionnaire to process the Veteran's claim.  
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;;
  1.  ;; NOTE: IHD includes, but is not limited to, acute, subacute, 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 include
  1.  ;; hypertension or peripheral manifestations of arteriosclerosis such as
  1.  ;; peripheral vascular disease or stroke, or any other condition that does not
  1.  ;; qualify within the generally accepted medical definition of ischemic heart
  1.  ;; disease.
  1.  ;; IHD encompasses any atherosclerotic heart disease resulting in clinically
  1.  ;; significant ischemia or requiring coronary revascularization.
  1.  ;;
  1.  ;; Does the Veteran have ischemic heart disease (IHD)?   ___ Yes   ___ No
  1.  ;;
  1.  ;; NOTE: Provide only diagnoses that pertain to IHD.
  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.  ;;^TOF^
  1.  ;; 2. Medical history
  1.  ;;
  1.  ;; Does the Veteran's treatment plan include taking continuous medication for
  1.  ;; the diagnosed condition?   ___ Yes   ___ No
  1.  ;;     List medications: _______________________________________________________
  1.  ;;
  1.  ;; Is there a history of:
  1.  ;;
  1.  ;; Percutaneous coronary intervention (PCI)   ___ Yes   ___ No
  1.  ;;     Treatment facility/date:_________________________________________________
  1.  ;;
  1.  ;; Myocardial infarction   ___ Yes   ___ No
  1.  ;;     Treatment facility/date:_________________________________________________
  1.  ;;
  1.  ;; Coronary bypass surgery   ___ Yes   ___ No
  1.  ;;     Treatment facility/date:_________________________________________________
  1.  ;;
  1.  ;; Heart transplant   ___ Yes   ___ No
  1.  ;;     Treatment facility/date:_________________________________________________
  1.  ;;     If yes, is it as likely as not that the Veteran's heart transplant is
  1.  ;;     due to IHD?   ___ Yes   ___ No
  1.  ;;
  1.  ;; Implanted cardiac pacemaker   ___ Yes   ___ No
  1.  ;;     Treatment facility/date:_________________________________________________
  1.  ;;     If yes, is it as likely as not that the Veteran's pacemaker is due to
  1.  ;;     IHD?   ___ Yes   ___ No
  1.  ;;
  1.  ;; Implanted automatic implantable cardioverter defibrillator (AICD)
  1.  ;;     ___ Yes   ___ No
  1.  ;;     Treatment facility/date: ________________________________________________
  1.  ;;     If yes, is it as likely as not that the Veteran's AICD is due to IHD?
  1.  ;;     ___ Yes   ___ No
  1.  ;;
  1.  ;; 3. Congestive heart failure (CHF)
  1.  ;;
  1.  ;; Does the Veteran have CHF?      ___ Yes   ___ No
  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.  ;; ______________________________________________________________________________
  1.  ;;^TOF^
  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 the
  1.  ;; 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 as
  1.  ;; part of Veteran's treatment plan, complete the following METs test based on
  1.  ;; the Veteran's responses:
  1.  ;;
  1.  ;; Lowest level of activity at which the Veteran reports symptoms (check all
  1.  ;; 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 lawn
  1.  ;;                  (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.  ;; ___ 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 suggested
  1.  ;; order of testing for cardiac hypertrophy/dilatation is EKG, then chest
  1.  ;; x-ray (PA and lateral), then echocardiogram. Echocardiogram is only
  1.  ;; necessary if the other two tests are negative. A limited echocardiogram, if
  1.  ;; available, is appropriate to determine if cardiac hypertrophy/dilatation is
  1.  ;; present by measuring only left ventricular dimension, wall thickness and
  1.  ;; 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.  ;; ___ Chest x-ray      Date of CXR: ______________
  1.  ;; ___ Echocardiogram   Date of echocardiogram:_______________
  1.  ;; ___ Other study (specify): ________    Date:_______________
  1.  ;;
  1.  ;; Left ventricular ejection fraction (LVEF), if known: ______%
  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 condition,
  1.  ;; LVEF testing is not required.
  1.  ;;
  1.  ;; 6. Functional impact 
  1.  ;; Does the Veteran's ischemic heart disease impact his or her ability to work?    
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe impact, providing one or more examples: ____________________
  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.  ;; ^END^
  1.  Q