DVBCQIM2 ;;ALB-CIOFO/ECF - INTESTINAL CONDITIONS QUESTIONNAIRE ; 6/20/2011
;;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
;; intestinal condition (other than surgical or infectious)?
;; ___ Yes ___ No
;;
;; If yes, select the Veteran's condition (check all that apply):
;; ___ Irritable bowel syndrome ICD code: _____ Date of diagnosis: _______
;; ___ Spastic colitis ICD code: ______ Date of diagnosis: _______
;; ___ Mucous colitis ICD code: ______ Date of diagnosis: _______
;; ___ Chronic diarrhea ICD code: ______ Date of diagnosis: _______
;; ___ Ulcerative colitis ICD code: ______ Date of diagnosis: _______
;; ___ Crohn's disease ICD code: ______ Date of diagnosis: _______
;; ___ Chronic enteritis ICD code: ______ Date of diagnosis: _______
;; ___ Chronic enterocolitis ICD code: ______ Date of diagnosis: _______
;; ___ Celiac disease ICD code: ______ Date of diagnosis: _______
;; ___ Diverticulitis ICD code: ______ Date of diagnosis: _______
;; ___ Intestinal neoplasm ICD code: ______ Date of diagnosis: _______
;; ___ Peritoneal adhesions attributable to diverticulitis
;; If checked, ALSO complete the Peritoneal Adhesions Questionnaire.
;; ICD code: ______ Date of diagnosis: _______
;; ___ Other non-surgical or non-infectious intestinal conditions:
;;
;; Other diagnosis #1: ______________
;; ICD code: _______________________
;; Date of diagnosis: _______________
;;
;; Other diagnosis #2: ______________
;; ICD code: _______________________
;; Date of diagnosis: _______________
;;
;; If there are additional diagnoses that pertain to intestinal conditions
;; (other than surgical or infectious), list using above format: ______________
;;
;; 2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's
;; intestinal condition (brief summary): ______________________________________
;;^TOF^
;; b. Is continuous medication required for control of the Veteran's intestinal
;; condition?
;; ___ Yes ___ No
;; If yes, list only those medications required for the intestinal condition:
;; ____________________________________________________________________________
;;
;; c. Has the Veteran had surgical treatment for an intestinal condition?
;; ___ Yes ___ No
;; If yes, ALSO complete the Intestinal Surgery Questionnaire.
;;
;; 3. Signs and symptoms
;;
;; Does the Veteran have any signs or symptoms attributable to any non-surgical
;; non-infectious intestinal conditions?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Diarrhea
;; If checked, describe: _______________________________________________
;; ___ Alternating diarrhea and constipation
;; If checked, describe: _______________________________________________
;; ___ Abdominal distension
;; If checked, describe: _______________________________________________
;; ___ Anemia
;; If checked, provide hemoglobin/hematocrit in Diagnostic testing
;; section.
;; ___ Nausea
;; If checked, describe: _______________________________________________
;; ___ Vomiting
;; If checked, describe: _______________________________________________
;; ___ Other, describe: ____________________________________________________
;;
;; 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 intestinal condition
;; (other than surgical or infectious 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 findings: (check all that apply)
;; ___ Health only fair during remissions
;; ___ General debility
;; ___ Serious complication such as liver abscess, describe: _______________
;; ___ Malnutrition
;; If checked, is malnutrition marked? ___ Yes ___ No
;; ___ Other, describe: ____________________________________________________
;;
;; Note: Complete additional Disability Questionnaire(s) for complications
;; noted, as deemed appropriate (schedule with appropriate provider)
;;
;; 7. Tumors and neoplasms
;;
;; a. Does the Veteran have a benign or malignant neoplasm or metastases
;; related to any of the diagnoses in the Diagnosis section?
;; ___ Yes ___ No
;; If yes, complete the following:
;;
;; b. Is the neoplasm
;; ___ Benign ___ Malignant
;;
;; c. Has the Veteran completed treatment or is the Veteran currently
;; undergoing treatment for a benign or malignant neoplasm or metastases?
;; ___ Yes ___ No; watchful waiting
;; If yes, indicate type of treatment the Veteran is currently undergoing
;; or has completed (check all that apply):
;; ___ Treatment completed; currently in watchful waiting status
;; ___ Surgery
;; If checked, describe: ______________________________________________
;; Date(s) of surgery: ______________________
;; ___ Radiation therapy
;; Date of most recent treatment: ___________
;; Date of completion of treatment or anticipated date of
;; completion: __________________
;;^TOF^
;; ___ Antineoplastic chemotherapy
;; Date of most recent treatment: ___________
;; Date of completion of treatment or anticipated date of
;; completion: __________________
;; ___ Other therapeutic procedure
;; If checked, describe procedure: ____________________________________
;; Date of most recent procedure: ___________
;; ___ Other therapeutic treatment
;; If checked, describe treatment: ____________________________________
;; Date of completion of treatment or anticipated date of
;; completion: __________________
;;
;; d. Does the Veteran currently have any residual conditions or complications
;; due to the neoplasm (including metastases) or its treatment, other than
;; those already documented in the report above?
;; ___ Yes ___ No
;; If yes, list residual conditions and complications (brief summary): ________
;; ____________________________________________________________________________
;;
;; e. If there are additional benign or malignant neoplasms or metastases
;; related to any of the diagnoses in the Diagnosis section, describe using
;; the above format: ____________________________________________
;;
;; 8. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;;
;; a. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs and/or symptoms?
;; ___ Yes ___ No
;; If yes, describe (brief summary): __________________________________________
;;
;; b. 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.
;;
;; 9. 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.
;;^TOF^
;; 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: _________________________________
;;
;; 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):
;; ____________________________________________________________________________
;;
;; 10. Functional impact
;;
;; Does the Veteran's intestinal condition impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's intestinal conditions
;; providing one or more examples: ____________________________________________
;;
;; 11. Remarks, if any: _______________________________________________________
;;
;; Physician signature: ____________________________________ Date: ____________
;;
;; Physician printed name: _________________________________ Phone: ___________
;;
;; Medical license #: ______________________________________ FAX: _____________
;;
;; 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[HDVBCQIM2 11385 printed Sep 23, 2025@19:22:58 Page 2
DVBCQIM2 ;;ALB-CIOFO/ECF - INTESTINAL CONDITIONS QUESTIONNAIRE ; 6/20/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran now have or has he/she ever been diagnosed with an
+10 ;; intestinal condition (other than surgical or infectious)?
+11 ;; ___ Yes ___ No
+12 ;;
+13 ;; If yes, select the Veteran's condition (check all that apply):
+14 ;; ___ Irritable bowel syndrome ICD code: _____ Date of diagnosis: _______
+15 ;; ___ Spastic colitis ICD code: ______ Date of diagnosis: _______
+16 ;; ___ Mucous colitis ICD code: ______ Date of diagnosis: _______
+17 ;; ___ Chronic diarrhea ICD code: ______ Date of diagnosis: _______
+18 ;; ___ Ulcerative colitis ICD code: ______ Date of diagnosis: _______
+19 ;; ___ Crohn's disease ICD code: ______ Date of diagnosis: _______
+20 ;; ___ Chronic enteritis ICD code: ______ Date of diagnosis: _______
+21 ;; ___ Chronic enterocolitis ICD code: ______ Date of diagnosis: _______
+22 ;; ___ Celiac disease ICD code: ______ Date of diagnosis: _______
+23 ;; ___ Diverticulitis ICD code: ______ Date of diagnosis: _______
+24 ;; ___ Intestinal neoplasm ICD code: ______ Date of diagnosis: _______
+25 ;; ___ Peritoneal adhesions attributable to diverticulitis
+26 ;; If checked, ALSO complete the Peritoneal Adhesions Questionnaire.
+27 ;; ICD code: ______ Date of diagnosis: _______
+28 ;; ___ Other non-surgical or non-infectious intestinal conditions:
+29 ;;
+30 ;; Other diagnosis #1: ______________
+31 ;; ICD code: _______________________
+32 ;; Date of diagnosis: _______________
+33 ;;
+34 ;; Other diagnosis #2: ______________
+35 ;; ICD code: _______________________
+36 ;; Date of diagnosis: _______________
+37 ;;
+38 ;; If there are additional diagnoses that pertain to intestinal conditions
+39 ;; (other than surgical or infectious), list using above format: ______________
+40 ;;
+41 ;; 2. Medical history
+42 ;;
+43 ;; a. Describe the history (including onset and course) of the Veteran's
+44 ;; intestinal condition (brief summary): ______________________________________
+45 ;;^TOF^
+46 ;; b. Is continuous medication required for control of the Veteran's intestinal
+47 ;; condition?
+48 ;; ___ Yes ___ No
+49 ;; If yes, list only those medications required for the intestinal condition:
+50 ;; ____________________________________________________________________________
+51 ;;
+52 ;; c. Has the Veteran had surgical treatment for an intestinal condition?
+53 ;; ___ Yes ___ No
+54 ;; If yes, ALSO complete the Intestinal Surgery Questionnaire.
+55 ;;
+56 ;; 3. Signs and symptoms
+57 ;;
+58 ;; Does the Veteran have any signs or symptoms attributable to any non-surgical
+59 ;; non-infectious intestinal conditions?
+60 ;; ___ Yes ___ No
+61 ;; If yes, check all that apply:
+62 ;; ___ Diarrhea
+63 ;; If checked, describe: _______________________________________________
+64 ;; ___ Alternating diarrhea and constipation
+65 ;; If checked, describe: _______________________________________________
+66 ;; ___ Abdominal distension
+67 ;; If checked, describe: _______________________________________________
+68 ;; ___ Anemia
+69 ;; If checked, provide hemoglobin/hematocrit in Diagnostic testing
+70 ;; section.
+71 ;; ___ Nausea
+72 ;; If checked, describe: _______________________________________________
+73 ;; ___ Vomiting
+74 ;; If checked, describe: _______________________________________________
+75 ;; ___ Other, describe: ____________________________________________________
+76 ;;
+77 ;; 4. Symptom episodes, attacks and exacerbations
+78 ;;
+79 ;; Does the Veteran have episodes of bowel disturbance with abdominal distress,
+80 ;; or exacerbations or attacks of the intestinal condition?
+81 ;; ___ Yes ___ No
+82 ;; If yes, indicate severity and frequency: (check all that apply)
+83 ;; ___ Episodes of bowel disturbance with abdominal distress
+84 ;; If checked, indicate frequency:
+85 ;; ___ Occasional episodes
+86 ;; ___ Frequent episodes
+87 ;; ___ More or less constant abdominal distress
+88 ;; ___ Episodes of exacerbations and/or attacks of the intestinal condition
+89 ;; If checked, describe typical exacerbation or attack: ________________
+90 ;; Indicate number of exacerbations and/or attacks in past 12 months:
+91 ;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 ___ 5 ___ 6 ___ 7 or more
+92 ;;^TOF^
+93 ;; 5. Weight loss
+94 ;;
+95 ;; Does the Veteran have weight loss attributable to an intestinal condition
+96 ;; (other than surgical or infectious condition)?
+97 ;; ___ Yes ___ No
+98 ;; If yes, provide Veteran's baseline weight: _______ and current weight: _____
+99 ;; (For VA purposes, baseline weight is the average weight for 2-year period
+100 ;; preceding onset of disease)
+101 ;;
+102 ;; 6. Malnutrition, complications and other general health effects
+103 ;;
+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 findings: (check all that apply)
+108 ;; ___ Health only fair during remissions
+109 ;; ___ General debility
+110 ;; ___ Serious complication such as liver abscess, describe: _______________
+111 ;; ___ Malnutrition
+112 ;; If checked, is malnutrition marked? ___ Yes ___ No
+113 ;; ___ Other, describe: ____________________________________________________
+114 ;;
+115 ;; Note: Complete additional Disability Questionnaire(s) for complications
+116 ;; noted, as deemed appropriate (schedule with appropriate provider)
+117 ;;
+118 ;; 7. Tumors and neoplasms
+119 ;;
+120 ;; a. Does the Veteran have a benign or malignant neoplasm or metastases
+121 ;; related to any of the diagnoses in the Diagnosis section?
+122 ;; ___ Yes ___ No
+123 ;; If yes, complete the following:
+124 ;;
+125 ;; b. Is the neoplasm
+126 ;; ___ Benign ___ Malignant
+127 ;;
+128 ;; c. Has the Veteran completed treatment or is the Veteran currently
+129 ;; undergoing treatment for a benign or malignant neoplasm or metastases?
+130 ;; ___ Yes ___ No; watchful waiting
+131 ;; If yes, indicate type of treatment the Veteran is currently undergoing
+132 ;; or has completed (check all that apply):
+133 ;; ___ Treatment completed; currently in watchful waiting status
+134 ;; ___ Surgery
+135 ;; If checked, describe: ______________________________________________
+136 ;; Date(s) of surgery: ______________________
+137 ;; ___ Radiation therapy
+138 ;; Date of most recent treatment: ___________
+139 ;; Date of completion of treatment or anticipated date of
+140 ;; completion: __________________
+141 ;;^TOF^
+142 ;; ___ Antineoplastic chemotherapy
+143 ;; Date of most recent treatment: ___________
+144 ;; Date of completion of treatment or anticipated date of
+145 ;; completion: __________________
+146 ;; ___ Other therapeutic procedure
+147 ;; If checked, describe procedure: ____________________________________
+148 ;; Date of most recent procedure: ___________
+149 ;; ___ Other therapeutic treatment
+150 ;; If checked, describe treatment: ____________________________________
+151 ;; Date of completion of treatment or anticipated date of
+152 ;; completion: __________________
+153 ;;
+154 ;; d. Does the Veteran currently have any residual conditions or complications
+155 ;; due to the neoplasm (including metastases) or its treatment, other than
+156 ;; those already documented in the report above?
+157 ;; ___ Yes ___ No
+158 ;; If yes, list residual conditions and complications (brief summary): ________
+159 ;; ____________________________________________________________________________
+160 ;;
+161 ;; e. If there are additional benign or malignant neoplasms or metastases
+162 ;; related to any of the diagnoses in the Diagnosis section, describe using
+163 ;; the above format: ____________________________________________
+164 ;;
+165 ;; 8. Other pertinent physical findings, complications, conditions, signs
+166 ;; and/or symptoms
+167 ;;
+168 ;; a. Does the Veteran have any other pertinent physical findings,
+169 ;; complications, conditions, signs and/or symptoms?
+170 ;; ___ Yes ___ No
+171 ;; If yes, describe (brief summary): __________________________________________
+172 ;;
+173 ;; b. Does the Veteran have any scars (surgical or otherwise) related to any
+174 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+175 ;; section above?
+176 ;; ___ Yes ___ No
+177 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+178 ;; of all related scars greater than 39 square cm (6 square inches)?
+179 ;; ___ Yes ___ No
+180 ;; If yes, also complete a Scars Questionnaire.
+181 ;;
+182 ;; 9. Diagnostic testing
+183 ;;
+184 ;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has
+185 ;; been performed and reflects the Veteran's current condition, provide most
+186 ;; recent results; no further studies or testing are required for this
+187 ;; examination.
+188 ;;^TOF^
+189 ;; a. Has laboratory testing been performed?
+190 ;; ___ Yes ___ No
+191 ;; If yes, check all that apply:
+192 ;; ___ CBC (if anemia due to any intestinal condition is suspected or
+193 ;; present)
+194 ;; Date of test: _______________________________________________
+195 ;; Hemoglobin: _________________________ Hematocrit: __________________
+196 ;; White blood cell count: _____________ Platelets: ___________________
+197 ;; ___ Other, specify: _____________________________________________________
+198 ;; Date of test: ___________ Results: _________________________________
+199 ;;
+200 ;; b. Have imaging studies or diagnostic procedures been performed and are the
+201 ;; results available?
+202 ;; ___ Yes ___ No
+203 ;; If yes, provide type of test or procedure, date and results (brief summary):
+204 ;; ____________________________________________________________________________
+205 ;;
+206 ;; c. Are there any other significant diagnostic test findings and/or results?
+207 ;; ___ Yes ___ No
+208 ;; If yes, provide type of test or procedure, date and results (brief summary):
+209 ;; ____________________________________________________________________________
+210 ;;
+211 ;; 10. Functional impact
+212 ;;
+213 ;; Does the Veteran's intestinal condition impact his or her ability to work?
+214 ;; ___ Yes ___ No
+215 ;; If yes, describe the impact of each of the Veteran's intestinal conditions
+216 ;; providing one or more examples: ____________________________________________
+217 ;;
+218 ;; 11. Remarks, if any: _______________________________________________________
+219 ;;
+220 ;; Physician signature: ____________________________________ Date: ____________
+221 ;;
+222 ;; Physician printed name: _________________________________ Phone: ___________
+223 ;;
+224 ;; Medical license #: ______________________________________ FAX: _____________
+225 ;;
+226 ;; Physician address: _________________________________________________________
+227 ;;
+228 ;; NOTE: VA may request additional medical information, including additional
+229 ;; examinations if necessary to complete VA's review of the Veteran's
+230 ;; application.
+231 ;;
+232 ;;^END^
+233 QUIT
