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Routine: DVBCQIM2

DVBCQIM2.m

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  1. DVBCQIM2 ;;ALB-CIOFO/ECF - INTESTINAL CONDITIONS QUESTIONNAIRE ; 6/20/2011
  1. ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
  1. ;
  1. TXT ;
  1. ;;
  1. ;; Your patient is applying to the U. S. Department of Veterans Affairs
  1. ;; (VA) for disability benefits. VA will consider the information you
  1. ;; provide on this questionnaire as part of their evaluation in processing
  1. ;; the Veteran's claim.
  1. ;;
  1. ;; 1. Diagnosis
  1. ;;
  1. ;; Does the Veteran now have or has he/she ever been diagnosed with an
  1. ;; intestinal condition (other than surgical or infectious)?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, select the Veteran's condition (check all that apply):
  1. ;; ___ Irritable bowel syndrome ICD code: _____ Date of diagnosis: _______
  1. ;; ___ Spastic colitis ICD code: ______ Date of diagnosis: _______
  1. ;; ___ Mucous colitis ICD code: ______ Date of diagnosis: _______
  1. ;; ___ Chronic diarrhea ICD code: ______ Date of diagnosis: _______
  1. ;; ___ Ulcerative colitis ICD code: ______ Date of diagnosis: _______
  1. ;; ___ Crohn's disease ICD code: ______ Date of diagnosis: _______
  1. ;; ___ Chronic enteritis ICD code: ______ Date of diagnosis: _______
  1. ;; ___ Chronic enterocolitis ICD code: ______ Date of diagnosis: _______
  1. ;; ___ Celiac disease ICD code: ______ Date of diagnosis: _______
  1. ;; ___ Diverticulitis ICD code: ______ Date of diagnosis: _______
  1. ;; ___ Intestinal neoplasm ICD code: ______ Date of diagnosis: _______
  1. ;; ___ Peritoneal adhesions attributable to diverticulitis
  1. ;; If checked, ALSO complete the Peritoneal Adhesions Questionnaire.
  1. ;; ICD code: ______ Date of diagnosis: _______
  1. ;; ___ Other non-surgical or non-infectious intestinal conditions:
  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 intestinal conditions
  1. ;; (other than surgical or infectious), list using above format: ______________
  1. ;;
  1. ;; 2. Medical history
  1. ;;
  1. ;; a. Describe the history (including onset and course) of the Veteran's
  1. ;; intestinal condition (brief summary): ______________________________________
  1. ;;^TOF^
  1. ;; b. Is continuous medication required for control of the Veteran's intestinal
  1. ;; condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, list only those medications required for the intestinal condition:
  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. ;;
  1. ;; 3. Signs and symptoms
  1. ;;
  1. ;; Does the Veteran have any signs or symptoms attributable to any non-surgical
  1. ;; non-infectious intestinal conditions?
  1. ;; ___ Yes ___ No
  1. ;; If yes, check all that apply:
  1. ;; ___ Diarrhea
  1. ;; If checked, describe: _______________________________________________
  1. ;; ___ Alternating diarrhea and constipation
  1. ;; If checked, describe: _______________________________________________
  1. ;; ___ Abdominal distension
  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. ;; 4. Symptom episodes, attacks and exacerbations
  1. ;;
  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. ;; 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. ;;
  1. ;; Does the Veteran have weight loss attributable to an intestinal condition
  1. ;; (other than surgical or infectious 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. ;;
  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 findings: (check all that apply)
  1. ;; ___ Health only fair during remissions
  1. ;; ___ General debility
  1. ;; ___ Serious complication such as liver abscess, describe: _______________
  1. ;; ___ Malnutrition
  1. ;; If checked, is malnutrition marked? ___ Yes ___ No
  1. ;; ___ Other, describe: ____________________________________________________
  1. ;;
  1. ;; Note: Complete additional Disability Questionnaire(s) for complications
  1. ;; noted, as deemed appropriate (schedule with appropriate provider)
  1. ;;
  1. ;; 7. Tumors and neoplasms
  1. ;;
  1. ;; a. Does the Veteran have a benign or malignant neoplasm or metastases
  1. ;; related to any of the diagnoses in the Diagnosis section?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following:
  1. ;;
  1. ;; b. Is the neoplasm
  1. ;; ___ Benign ___ Malignant
  1. ;;
  1. ;; c. Has the Veteran completed treatment or is the Veteran currently
  1. ;; undergoing treatment for a benign or malignant neoplasm or metastases?
  1. ;; ___ Yes ___ No; watchful waiting
  1. ;; If yes, indicate type of treatment the Veteran is currently undergoing
  1. ;; or has completed (check all that apply):
  1. ;; ___ Treatment completed; currently in watchful waiting status
  1. ;; ___ Surgery
  1. ;; If checked, describe: ______________________________________________
  1. ;; Date(s) of surgery: ______________________
  1. ;; ___ Radiation therapy
  1. ;; Date of most recent treatment: ___________
  1. ;; Date of completion of treatment or anticipated date of
  1. ;; completion: __________________
  1. ;;^TOF^
  1. ;; ___ Antineoplastic chemotherapy
  1. ;; Date of most recent treatment: ___________
  1. ;; Date of completion of treatment or anticipated date of
  1. ;; completion: __________________
  1. ;; ___ Other therapeutic procedure
  1. ;; If checked, describe procedure: ____________________________________
  1. ;; Date of most recent procedure: ___________
  1. ;; ___ Other therapeutic treatment
  1. ;; If checked, describe treatment: ____________________________________
  1. ;; Date of completion of treatment or anticipated date of
  1. ;; completion: __________________
  1. ;;
  1. ;; d. Does the Veteran currently have any residual conditions or complications
  1. ;; due to the neoplasm (including metastases) or its treatment, other than
  1. ;; those already documented in the report above?
  1. ;; ___ Yes ___ No
  1. ;; If yes, list residual conditions and complications (brief summary): ________
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; e. If there are additional benign or malignant neoplasms or metastases
  1. ;; related to any of the diagnoses in the Diagnosis section, describe using
  1. ;; the above format: ____________________________________________
  1. ;;
  1. ;; 8. Other pertinent physical findings, complications, conditions, signs
  1. ;; and/or symptoms
  1. ;;
  1. ;; a. Does the Veteran have any other pertinent physical findings,
  1. ;; complications, conditions, signs and/or symptoms?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe (brief summary): __________________________________________
  1. ;;
  1. ;; b. 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
  1. ;; of all related scars greater than 39 square cm (6 square inches)?
  1. ;; ___ Yes ___ No
  1. ;; If yes, also complete a Scars Questionnaire.
  1. ;;
  1. ;; 9. Diagnostic testing
  1. ;;
  1. ;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has
  1. ;; been performed and reflects the Veteran's current condition, provide most
  1. ;; recent results; no further studies or testing are required for this
  1. ;; examination.
  1. ;;^TOF^
  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
  1. ;; present)
  1. ;; Date of test: _______________________________________________
  1. ;; Hemoglobin: _________________________ Hematocrit: __________________
  1. ;; White blood cell count: _____________ Platelets: ___________________
  1. ;; ___ Other, specify: _____________________________________________________
  1. ;; Date of test: ___________ Results: _________________________________
  1. ;;
  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. ;; 10. Functional impact
  1. ;;
  1. ;; Does the Veteran's intestinal condition impact his or her ability to work?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe the impact of each of the Veteran's intestinal conditions
  1. ;; providing one or more examples: ____________________________________________
  1. ;;
  1. ;; 11. Remarks, if any: _______________________________________________________
  1. ;;
  1. ;; Physician signature: ____________________________________ Date: ____________
  1. ;;
  1. ;; Physician printed name: _________________________________ Phone: ___________
  1. ;;
  1. ;; Medical license #: ______________________________________ FAX: _____________
  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