DVBCQII2 ;;ALB-CIOFO/SBW - INFECTIOUS INTESTINAL DISORDERS QUESTIONNAIRE ; 27/JUNE/2011
;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
;
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 now have or has he/she ever been diagnosed with an
;; infectious intestinal condition?
;; ___ Yes ___ No
;;
;; If yes, select the Veteran's condition (check all that apply):
;; __ Bacillary dysentery ICD code: ______ Date of diagnosis: ____________
;; __ Intestinal distomiasis
;; (intestinal fluke) ICD code: ______ Date of diagnosis: ____________
;; __ Parasitic infection of
;; the intestines ICD code: ______ Date of diagnosis: ____________
;; __ Amebiasis ICD code: ______ Date of diagnosis: ____________
;; If the Veteran has a lung abscess due to amebiasis, ALSO complete the
;; the Respiratory Questionnaire.
;; __ Other infectious intestinal condition
;;
;; Other diagnosis #1: __________________
;; ICD code: ____________________
;; Date of diagnosis: ______________
;;
;; Other diagnosis #2: __________________
;; ICD code: ____________________
;; Date of diagnosis: ______________
;;
;; If there are additional diagnoses that pertain to infectious intestinal
;; conditions, list using above format: ________________________________________
;;
;; 2. Medical History
;; a. Describe the history (including onset, course, and past treatment) of the
;; Veteran's infectious intestinal conditions (brief summary): _________________
;; _____________________________________________________________________________
;;
;; b. Is continuous medication required for control of the Veteran's intestinal
;; conditions?
;; ___ Yes ___ No
;; If yes, list only those medications required for the intestinal conditions:
;; _____________________________________________________________________________
;;
;; c. Has the Veteran had surgical treatment for an intestinal condition?
;; ___ Yes ___ No
;; If yes, ALSO complete the Intestinal Surgery Questionnaire.
;;^TOF^
;; 3. Signs and symptoms
;; Does the Veteran have any signs or symptoms attributable to any infectious
;; intestinal conditions?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Mild symptoms attributable to distomiasis, intestinal or hepatic
;; If checked, describe: _______________________________________________
;; ___ Moderate symptoms attributable to distomiasis, intestinal or hepatic
;; If checked, describe: _______________________________________________
;; ___ Severe symptoms attributable to distomiasis, intestinal or hepatic
;; If checked, describe: _______________________________________________
;; ___ Mild gastrointestinal disturbances
;; If checked, describe: _______________________________________________
;; ___ Lower abdominal cramps
;; If checked, describe: _______________________________________________
;; ___ Gaseous distention
;; If checked, describe: _______________________________________________
;; ___ Chronic constipation interrupted by diarrhea
;; If checked, describe: ______________________________________________
;; ___ Anemia
;; If checked, provide hemoglobin/hematocrit in Diagnostic testing
;; section.
;; ___ Nausea
;; If checked, describe: _______________________________________________
;; ___ Vomiting
;; If checked, describe: _______________________________________________
;; ___ Other, describe: _____________________________________________________
;;
;; Note: Complete the appropriate Disability Questionnaire(s) when the
;; infectious disease affects other organs such as the liver, lung, kidney, etc.
;; (schedule with appropriate provider)
;;
;; 4. Symptom episodes, attacks and exacerbations
;; Does the Veteran have episodes of bowel disturbance with abdominal distress,
;; or exacerbations or attacks of the intestinal condition?
;; ___ Yes ___ No
;; If yes, indicate severity and frequency: (check all that apply)
;; ___ Episodes of bowel disturbance with abdominal distress
;; If checked, indicate frequency:
;; ___ Occasional episodes
;; ___ Frequent episodes
;; ___ More or less constant abdominal distress
;; ___ Episodes of exacerbations and/or attacks of the intestinal condition
;; If checked, describe typical exacerbation or attack: ________________
;; _____________________________________________________________________
;; Indicate number of exacerbations and/or attacks in past 12 months:
;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ 6 ___ 7 or more
;;^TOF^
;; 5. Weight loss
;; Does the Veteran have weight loss attributable to an infectious intestinal
;; condition?
;; ___ Yes ___ No
;; If yes, provide Veteran's baseline weight: _______ and current weight: _______
;; (For VA purposes, baseline weight is the average weight for 2-year period
;; preceding onset of disease)
;;
;; 6. Malnutrition, complications and other general health effects
;; Does the Veteran have malnutrition, serious complications or other general
;; health effects attributable to the intestinal condition?
;; ___ Yes ___ No
;; If yes, indicate severity: (check all that apply)
;; ___ Health only fair during remissions
;; ___ Resulting in general debility
;; ___ Resulting in serious complication such as liver abscess
;; ___ Malnutrition
;; If checked, is malnutrition marked? ___ Yes ___ No
;; ___ Other, describe: _____________________________________________________
;;
;; 7. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;; a. Does the Veteran have any scars (surgical or otherwise) related to any
;; conditions or to the treatment of any conditions listed in the Diagnosis
;; section above?
;; ___ Yes ___ No
;; If yes, are any of the scars painful and/or unstable, or is the total area of
;; all related scars greater than 39 square cm (6 square inches)?
;; ___ Yes ___ No
;; If yes, also complete a Scars Questionnaire.
;;
;; b. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs and/or symptoms related to any conditions
;; listed in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): ___________________________________________
;;
;; 8. Diagnostic testing
;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has been
;; performed and reflects the Veteran's current condition, provide most recent
;; results; no further studies or testing are required for this examination.
;;
;; a. Has laboratory testing been performed?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ CBC (if anemia due to any intestinal condition is suspected or present)
;; Date of test: ___________
;; Hemoglobin: ______ Hematocrit: _______
;; White blood cell count: ______ Platelets: _____
;; ___ Other, specify: ______ Date of test: ___________ Results: __________
;;^TOF^
;; b. Have imaging studies or diagnostic procedures been performed and are the
;; results available?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;
;; c. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;;If yes, provide type of test or procedure, date and results (brief summary):
;; ___________________________________________________________ _________________
;;
;; 9. Functional impact
;; Do any of the Veteran's infectious intestinal conditions impact his or her
;; ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's infectious intestinal
;; conditions, providing one or more examples: _________________________________
;; _____________________________________________________________________________
;;
;; 10. Remarks, if any: ________________________________________________________
;;
;; Physician signature: _____________________________________ Date: ____________
;;
;; Physician printed name: _______________________________________
;;
;; Medical license #: _____________ Physician address: _________________________
;;
;; Phone: ____________________________ Fax: ____________________________
;;
;; 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[HDVBCQII2 9207 printed Apr 09, 2024@20:57:39 Page 2
DVBCQII2 ;;ALB-CIOFO/SBW - INFECTIOUS INTESTINAL DISORDERS QUESTIONNAIRE ; 27/JUNE/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;;
+5 ;; 1. Diagnosis
+6 ;; Does the Veteran now have or has he/she ever been diagnosed with an
+7 ;; infectious intestinal condition?
+8 ;; ___ Yes ___ No
+9 ;;
+10 ;; If yes, select the Veteran's condition (check all that apply):
+11 ;; __ Bacillary dysentery ICD code: ______ Date of diagnosis: ____________
+12 ;; __ Intestinal distomiasis
+13 ;; (intestinal fluke) ICD code: ______ Date of diagnosis: ____________
+14 ;; __ Parasitic infection of
+15 ;; the intestines ICD code: ______ Date of diagnosis: ____________
+16 ;; __ Amebiasis ICD code: ______ Date of diagnosis: ____________
+17 ;; If the Veteran has a lung abscess due to amebiasis, ALSO complete the
+18 ;; the Respiratory Questionnaire.
+19 ;; __ Other infectious intestinal condition
+20 ;;
+21 ;; Other diagnosis #1: __________________
+22 ;; ICD code: ____________________
+23 ;; Date of diagnosis: ______________
+24 ;;
+25 ;; Other diagnosis #2: __________________
+26 ;; ICD code: ____________________
+27 ;; Date of diagnosis: ______________
+28 ;;
+29 ;; If there are additional diagnoses that pertain to infectious intestinal
+30 ;; conditions, list using above format: ________________________________________
+31 ;;
+32 ;; 2. Medical History
+33 ;; a. Describe the history (including onset, course, and past treatment) of the
+34 ;; Veteran's infectious intestinal conditions (brief summary): _________________
+35 ;; _____________________________________________________________________________
+36 ;;
+37 ;; b. Is continuous medication required for control of the Veteran's intestinal
+38 ;; conditions?
+39 ;; ___ Yes ___ No
+40 ;; If yes, list only those medications required for the intestinal conditions:
+41 ;; _____________________________________________________________________________
+42 ;;
+43 ;; c. Has the Veteran had surgical treatment for an intestinal condition?
+44 ;; ___ Yes ___ No
+45 ;; If yes, ALSO complete the Intestinal Surgery Questionnaire.
+46 ;;^TOF^
+47 ;; 3. Signs and symptoms
+48 ;; Does the Veteran have any signs or symptoms attributable to any infectious
+49 ;; intestinal conditions?
+50 ;; ___ Yes ___ No
+51 ;; If yes, check all that apply:
+52 ;; ___ Mild symptoms attributable to distomiasis, intestinal or hepatic
+53 ;; If checked, describe: _______________________________________________
+54 ;; ___ Moderate symptoms attributable to distomiasis, intestinal or hepatic
+55 ;; If checked, describe: _______________________________________________
+56 ;; ___ Severe symptoms attributable to distomiasis, intestinal or hepatic
+57 ;; If checked, describe: _______________________________________________
+58 ;; ___ Mild gastrointestinal disturbances
+59 ;; If checked, describe: _______________________________________________
+60 ;; ___ Lower abdominal cramps
+61 ;; If checked, describe: _______________________________________________
+62 ;; ___ Gaseous distention
+63 ;; If checked, describe: _______________________________________________
+64 ;; ___ Chronic constipation interrupted by diarrhea
+65 ;; If checked, describe: ______________________________________________
+66 ;; ___ Anemia
+67 ;; If checked, provide hemoglobin/hematocrit in Diagnostic testing
+68 ;; section.
+69 ;; ___ Nausea
+70 ;; If checked, describe: _______________________________________________
+71 ;; ___ Vomiting
+72 ;; If checked, describe: _______________________________________________
+73 ;; ___ Other, describe: _____________________________________________________
+74 ;;
+75 ;; Note: Complete the appropriate Disability Questionnaire(s) when the
+76 ;; infectious disease affects other organs such as the liver, lung, kidney, etc.
+77 ;; (schedule with appropriate provider)
+78 ;;
+79 ;; 4. Symptom episodes, attacks and exacerbations
+80 ;; Does the Veteran have episodes of bowel disturbance with abdominal distress,
+81 ;; or exacerbations or attacks of the intestinal condition?
+82 ;; ___ Yes ___ No
+83 ;; If yes, indicate severity and frequency: (check all that apply)
+84 ;; ___ Episodes of bowel disturbance with abdominal distress
+85 ;; If checked, indicate frequency:
+86 ;; ___ Occasional episodes
+87 ;; ___ Frequent episodes
+88 ;; ___ More or less constant abdominal distress
+89 ;; ___ Episodes of exacerbations and/or attacks of the intestinal condition
+90 ;; If checked, describe typical exacerbation or attack: ________________
+91 ;; _____________________________________________________________________
+92 ;; Indicate number of exacerbations and/or attacks in past 12 months:
+93 ;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ 6 ___ 7 or more
+94 ;;^TOF^
+95 ;; 5. Weight loss
+96 ;; Does the Veteran have weight loss attributable to an infectious intestinal
+97 ;; condition?
+98 ;; ___ Yes ___ No
+99 ;; If yes, provide Veteran's baseline weight: _______ and current weight: _______
+100 ;; (For VA purposes, baseline weight is the average weight for 2-year period
+101 ;; preceding onset of disease)
+102 ;;
+103 ;; 6. Malnutrition, complications and other general health effects
+104 ;; Does the Veteran have malnutrition, serious complications or other general
+105 ;; health effects attributable to the intestinal condition?
+106 ;; ___ Yes ___ No
+107 ;; If yes, indicate severity: (check all that apply)
+108 ;; ___ Health only fair during remissions
+109 ;; ___ Resulting in general debility
+110 ;; ___ Resulting in serious complication such as liver abscess
+111 ;; ___ Malnutrition
+112 ;; If checked, is malnutrition marked? ___ Yes ___ No
+113 ;; ___ Other, describe: _____________________________________________________
+114 ;;
+115 ;; 7. Other pertinent physical findings, complications, conditions, signs
+116 ;; and/or symptoms
+117 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+118 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+119 ;; section above?
+120 ;; ___ Yes ___ No
+121 ;; If yes, are any of the scars painful and/or unstable, or is the total area of
+122 ;; all related scars greater than 39 square cm (6 square inches)?
+123 ;; ___ Yes ___ No
+124 ;; If yes, also complete a Scars Questionnaire.
+125 ;;
+126 ;; b. Does the Veteran have any other pertinent physical findings,
+127 ;; complications, conditions, signs and/or symptoms related to any conditions
+128 ;; listed in the Diagnosis section above?
+129 ;; ___ Yes ___ No
+130 ;; If yes, describe (brief summary): ___________________________________________
+131 ;;
+132 ;; 8. Diagnostic testing
+133 ;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has been
+134 ;; performed and reflects the Veteran's current condition, provide most recent
+135 ;; results; no further studies or testing are required for this examination.
+136 ;;
+137 ;; a. Has laboratory testing been performed?
+138 ;; ___ Yes ___ No
+139 ;; If yes, check all that apply:
+140 ;; ___ CBC (if anemia due to any intestinal condition is suspected or present)
+141 ;; Date of test: ___________
+142 ;; Hemoglobin: ______ Hematocrit: _______
+143 ;; White blood cell count: ______ Platelets: _____
+144 ;; ___ Other, specify: ______ Date of test: ___________ Results: __________
+145 ;;^TOF^
+146 ;; b. Have imaging studies or diagnostic procedures been performed and are the
+147 ;; results available?
+148 ;; ___ Yes ___ No
+149 ;; If yes, provide type of test or procedure, date and results (brief summary):
+150 ;; ____________________________________________________________________________
+151 ;;
+152 ;; c. Are there any other significant diagnostic test findings and/or results?
+153 ;; ___ Yes ___ No
+154 ;;If yes, provide type of test or procedure, date and results (brief summary):
+155 ;; ___________________________________________________________ _________________
+156 ;;
+157 ;; 9. Functional impact
+158 ;; Do any of the Veteran's infectious intestinal conditions impact his or her
+159 ;; ability to work?
+160 ;; ___ Yes ___ No
+161 ;; If yes, describe the impact of each of the Veteran's infectious intestinal
+162 ;; conditions, providing one or more examples: _________________________________
+163 ;; _____________________________________________________________________________
+164 ;;
+165 ;; 10. Remarks, if any: ________________________________________________________
+166 ;;
+167 ;; Physician signature: _____________________________________ Date: ____________
+168 ;;
+169 ;; Physician printed name: _______________________________________
+170 ;;
+171 ;; Medical license #: _____________ Physician address: _________________________
+172 ;;
+173 ;; Phone: ____________________________ Fax: ____________________________
+174 ;;
+175 ;; NOTE: VA may request additional medical information, including additional
+176 ;; examinations if necessary to complete VA's review of the Veteran's application.
+177 ;;^END^
+178 QUIT
