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Routine: DVBCQII2

DVBCQII2.m

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  1. DVBCQII2 ;;ALB-CIOFO/SBW - INFECTIOUS INTESTINAL DISORDERS QUESTIONNAIRE  ; 27/JUNE/2011
  1.  ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1.  ;; disability benefits. VA will consider the information you provide on this
  1.  ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with an
  1.  ;; infectious intestinal condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, select the Veteran's condition (check all that apply):
  1.  ;;    __ Bacillary dysentery    ICD code: ______  Date of diagnosis: ____________
  1.  ;;    __ Intestinal distomiasis
  1.  ;;       (intestinal fluke)     ICD code: ______  Date of diagnosis: ____________
  1.  ;;    __ Parasitic infection of
  1.  ;;       the intestines         ICD code: ______  Date of diagnosis: ____________
  1.  ;;    __ Amebiasis              ICD code: ______  Date of diagnosis: ____________
  1.  ;;          If the Veteran has a lung abscess due to amebiasis, ALSO complete the
  1.  ;;          the Respiratory Questionnaire.
  1.  ;;    __ Other infectious intestinal condition
  1.  ;;
  1.  ;;    Other diagnosis #1: __________________
  1.  ;;    ICD code:  ____________________
  1.  ;;    Date of diagnosis: ______________
  1.  ;;
  1.  ;;    Other diagnosis #2: __________________
  1.  ;;    ICD code:  ____________________
  1.  ;;    Date of diagnosis: ______________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to infectious intestinal
  1.  ;; conditions, list using above format: ________________________________________
  1.  ;;
  1.  ;; 2. Medical History
  1.  ;; a.  Describe the history (including onset, course, and past treatment) of the
  1.  ;; Veteran's infectious intestinal conditions (brief summary): _________________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; b. Is continuous medication required for control of the Veteran's intestinal
  1.  ;; conditions?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, list only those medications required for the intestinal conditions:
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; c. Has the Veteran had surgical treatment for an intestinal condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, ALSO complete the Intestinal Surgery Questionnaire.
  1.  ;;^TOF^
  1.  ;; 3. Signs and symptoms
  1.  ;; Does the Veteran have any signs or symptoms attributable to any infectious
  1.  ;; intestinal conditions?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Mild symptoms attributable to distomiasis, intestinal or hepatic
  1.  ;;         If checked, describe: _______________________________________________
  1.  ;;    ___ Moderate symptoms attributable to distomiasis, intestinal or hepatic
  1.  ;;         If checked, describe: _______________________________________________
  1.  ;;    ___ Severe symptoms attributable to distomiasis, intestinal or hepatic
  1.  ;;         If checked, describe: _______________________________________________
  1.  ;;    ___ Mild gastrointestinal disturbances
  1.  ;;         If checked, describe: _______________________________________________
  1.  ;;    ___ Lower abdominal cramps
  1.  ;;         If checked, describe: _______________________________________________
  1.  ;;    ___ Gaseous distention
  1.  ;;         If checked, describe: _______________________________________________
  1.  ;;    ___ Chronic constipation interrupted by diarrhea
  1.  ;;         If checked, describe: ______________________________________________
  1.  ;;    ___ Anemia
  1.  ;;         If checked, provide hemoglobin/hematocrit in Diagnostic testing
  1.  ;;         section.
  1.  ;;    ___ Nausea
  1.  ;;         If checked, describe: _______________________________________________
  1.  ;;    ___ Vomiting
  1.  ;;         If checked, describe: _______________________________________________
  1.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;
  1.  ;; Note: Complete the appropriate Disability Questionnaire(s) when the
  1.  ;; infectious disease affects other organs such as the liver, lung, kidney, etc.
  1.  ;; (schedule with appropriate provider)
  1.  ;;
  1.  ;; 4. Symptom episodes, attacks and exacerbations
  1.  ;; Does the Veteran have episodes of bowel disturbance with abdominal distress,
  1.  ;; or exacerbations or attacks of the intestinal condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate severity and frequency: (check all that apply)
  1.  ;;    ___ Episodes of bowel disturbance with abdominal distress
  1.  ;;    If checked, indicate frequency:
  1.  ;;         ___ Occasional episodes
  1.  ;;         ___ Frequent episodes
  1.  ;;         ___ More or less constant abdominal distress
  1.  ;;    ___ Episodes of exacerbations and/or attacks of the intestinal condition
  1.  ;;         If checked, describe typical exacerbation or attack: ________________
  1.  ;;         _____________________________________________________________________
  1.  ;;         Indicate number of exacerbations and/or attacks in past 12 months:
  1.  ;;         ___ 0   ___ 1   ___ 2   ___ 3   ___ 4   ___ 5   ___ 6   ___ 7 or more
  1.  ;;^TOF^
  1.  ;; 5. Weight loss
  1.  ;; Does the Veteran have weight loss attributable to an infectious intestinal
  1.  ;; condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide Veteran's baseline weight: _______ and current weight: _______
  1.  ;; (For VA purposes, baseline weight is the average weight for 2-year period
  1.  ;; preceding onset of disease)
  1.  ;;
  1.  ;; 6. Malnutrition, complications and other general health effects
  1.  ;; Does the Veteran have malnutrition, serious complications or other general
  1.  ;; health effects attributable to the intestinal condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate severity: (check all that apply)
  1.  ;;    ___ Health only fair during remissions
  1.  ;;    ___ Resulting in general debility
  1.  ;;    ___ Resulting in serious complication such as liver abscess
  1.  ;;    ___ Malnutrition
  1.  ;;          If checked, is malnutrition marked? ___ Yes   ___ No
  1.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;
  1.  ;; 7. Other pertinent physical findings, complications, conditions, signs
  1.  ;;    and/or symptoms
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, are any of the scars painful and/or unstable, or is the total area of
  1.  ;; all related scars greater than 39 square cm (6 square inches)?
  1.  ;;      ___ Yes   ___ No
  1.  ;;           If yes, also complete a Scars Questionnaire.
  1.  ;;
  1.  ;; b.  Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs and/or symptoms related to any conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): ___________________________________________
  1.  ;;
  1.  ;; 8. Diagnostic testing
  1.  ;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has been
  1.  ;; performed and reflects the Veteran's current condition, provide most recent
  1.  ;; results; no further studies or testing are required for this examination.
  1.  ;;
  1.  ;; a. Has laboratory testing been performed?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ CBC (if anemia due to any intestinal condition is suspected or present)
  1.  ;;          Date of test: ___________
  1.  ;;          Hemoglobin: ______  Hematocrit: _______
  1.  ;;          White blood cell count: ______  Platelets: _____
  1.  ;;    ___ Other, specify: ______  Date of test: ___________  Results: __________
  1.  ;;^TOF^
  1.  ;; b. Have imaging studies or diagnostic procedures been performed and are the
  1.  ;; results available?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;;  ____________________________________________________________________________
  1.  ;;
  1.  ;; c. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;;If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; ___________________________________________________________ _________________
  1.  ;;
  1.  ;; 9. Functional impact 
  1.  ;; Do any of the Veteran's infectious intestinal conditions impact his or her
  1.  ;; ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe the impact of each of the Veteran's infectious intestinal
  1.  ;; conditions, providing one or more examples: _________________________________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 10. Remarks, if any: ________________________________________________________
  1.  ;;
  1.  ;; Physician signature: _____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: _______________________________________ 
  1.  ;;
  1.  ;; Medical license #: _____________ Physician address: _________________________
  1.  ;;
  1.  ;; Phone: ____________________________ Fax: ____________________________
  1.  ;;
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's application.
  1.  ;;^END^
  1.  Q