- 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 Feb 18, 2025@23:13:20 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