DVBCQIS2 ;;ALB-CIOFO/ECF - INTESTINES - SURGICAL QUESTIONNAIRE ; 27/JUN/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
;; Has the Veteran had intestinal surgery?
;; ___ Yes ___ No
;;
;; If yes, select the Veteran's condition (check all that apply):
;; ___ Resection of the small intestine
;; ICD code:______ Date of diagnosis:_______ Reason for surgery:________
;; ___ Resection of the large intestine
;; ICD code:______ Date of diagnosis:_______ Reason for surgery:________
;; ___ Peritoneal adhesions attributable to resection of the large or small
;; intestine
;; If checked, ALSO complete the Peritoneal Adhesions Questionnaire.
;; ICD code:______ Date of diagnosis:_______ Reason for surgery:________
;; ___ Persistent fistula
;; ICD code:______ Date of diagnosis:_______ Reason for surgery:________
;; ___ Other intestinal surgery, specify diagnoses below, providing only
;; diagnoses that pertain to intestinal surgery:
;;
;; Other diagnosis #1: __________________
;; ICD code: ___________________________
;; Date of diagnosis: ___________________
;; Reason for surgery: _________________
;;
;; Other diagnosis #2: __________________
;; ICD code: ___________________________
;; Date of diagnosis: ___________________
;; Reason for surgery: _________________
;;
;; If there are additional diagnoses that pertain to intestinal surgery, list
;; using above format: _________________________________________________________
;;
;; 2. Medical History
;; a. Describe the history (including onset and course) of the Veteran's
;; intestinal surgery (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:
;; _____________________________________________________________________________
;;^TOF^
;; 3. Signs and symptoms
;; Does the Veteran have any signs or symptoms attributable to any intestinal
;; surgery?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Slight symptoms attributable to resection of large intestine
;; If checked, describe: ________________________________________________
;; ___ Moderate symptoms attributable to resection of large intestine
;; If checked, describe: ________________________________________________
;; ___ Severe symptoms, objectively supported by examination findings,
;; attributable to resection of large intestine
;; If checked, describe: ________________________________________________
;; ___ Abdominal pain and/or colic pain
;; If checked, describe: ________________________________________________
;; ___ 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: ________________________________________________
;; ___ Pulling pain on attempting work or aggravated by movements of the body
;; ___ Other, describe: _____________________________________________________
;;
;; 4. Weight loss
;; Does the Veteran have weight loss or inability to gain weight attributable to
;; intestinal surgery?
;; ___ Yes ___ No
;; If yes, complete the following section:
;;
;; a. 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)
;;
;; b. Has the Veteran's weight loss been sustained for 3 months or longer?
;; ___ Yes ___ No
;;
;; c. Has the Veteran been unable to regain weight despite appropriate therapy?
;; ___ Yes ___ No
;;^TOF^
;; 5. Absorption and nutrition
;; Does the Veteran have any interference with absorption and nutrition
;; attributable to resection of the small intestine?
;; ___ Yes ___ No ___ not applicable
;; If yes, does this cause impairment of health objectively supported by
;; examination findings including definite and/or material weight loss?
;; ___ Yes ___ No
;; If yes, is impairment of health severe?
;; ___ Yes ___ No
;; Indicate severity of interference with absorption and nutrition:
;; ___ Definite ___ Marked
;;
;; 6. Ostomy
;; Did the Veteran's intestinal condition require an ileostomy or colostomy?
;; ___ Yes ___ No
;; If yes, describe: ___________________________________________________________
;;
;; 7. Fistula
;; Does the Veteran now have or has he or she ever had a persistent intestinal
;; fistula attributable to a surgical intestinal condition?
;; ___ Yes ___ No
;; If yes, does the Veteran have fecal discharge attributable to this?
;; ___ Yes ___ No
;; If yes, indicate the severity and frequency of fecal discharge (check all
;; that apply):
;; ___ Slight
;; ___ Copious
;; ___ Infrequent
;; ___ Frequent
;; ___ Constant
;; ___ Other, describe: _____________________________________________________
;;
;; 8. 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): ___________________________________________
;;^TOF^
;; 9. Diagnostic testing
;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has
;; been performed and reflects the Veteran's current condition, 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: __________
;;
;; 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
;; Do any of the Veteran's intestinal surgery residuals impact his or her
;; ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's intestinal surgery
;; residuals, including any ongoing symptoms of original cause of surgery that
;; may be hard to distinguish from post-surgical residuals, providing one or
;; more examples: ______________________________________________________________
;;
;; 11. 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[HDVBCQIS2 9241 printed Apr 09, 2024@20:45:50 Page 2
DVBCQIS2 ;;ALB-CIOFO/ECF - INTESTINES - SURGICAL QUESTIONNAIRE ; 27/JUN/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 ;; Has the Veteran had intestinal surgery?
+7 ;; ___ Yes ___ No
+8 ;;
+9 ;; If yes, select the Veteran's condition (check all that apply):
+10 ;; ___ Resection of the small intestine
+11 ;; ICD code:______ Date of diagnosis:_______ Reason for surgery:________
+12 ;; ___ Resection of the large intestine
+13 ;; ICD code:______ Date of diagnosis:_______ Reason for surgery:________
+14 ;; ___ Peritoneal adhesions attributable to resection of the large or small
+15 ;; intestine
+16 ;; If checked, ALSO complete the Peritoneal Adhesions Questionnaire.
+17 ;; ICD code:______ Date of diagnosis:_______ Reason for surgery:________
+18 ;; ___ Persistent fistula
+19 ;; ICD code:______ Date of diagnosis:_______ Reason for surgery:________
+20 ;; ___ Other intestinal surgery, specify diagnoses below, providing only
+21 ;; diagnoses that pertain to intestinal surgery:
+22 ;;
+23 ;; Other diagnosis #1: __________________
+24 ;; ICD code: ___________________________
+25 ;; Date of diagnosis: ___________________
+26 ;; Reason for surgery: _________________
+27 ;;
+28 ;; Other diagnosis #2: __________________
+29 ;; ICD code: ___________________________
+30 ;; Date of diagnosis: ___________________
+31 ;; Reason for surgery: _________________
+32 ;;
+33 ;; If there are additional diagnoses that pertain to intestinal surgery, list
+34 ;; using above format: _________________________________________________________
+35 ;;
+36 ;; 2. Medical History
+37 ;; a. Describe the history (including onset and course) of the Veteran's
+38 ;; intestinal surgery (brief summary): _________________________________________
+39 ;;
+40 ;; b. Is continuous medication required for control of the Veteran's intestinal
+41 ;; conditions?
+42 ;; ___ Yes ___ No
+43 ;; If yes, list only those medications required for the intestinal conditions:
+44 ;; _____________________________________________________________________________
+45 ;;^TOF^
+46 ;; 3. Signs and symptoms
+47 ;; Does the Veteran have any signs or symptoms attributable to any intestinal
+48 ;; surgery?
+49 ;; ___ Yes ___ No
+50 ;; If yes, check all that apply:
+51 ;; ___ Slight symptoms attributable to resection of large intestine
+52 ;; If checked, describe: ________________________________________________
+53 ;; ___ Moderate symptoms attributable to resection of large intestine
+54 ;; If checked, describe: ________________________________________________
+55 ;; ___ Severe symptoms, objectively supported by examination findings,
+56 ;; attributable to resection of large intestine
+57 ;; If checked, describe: ________________________________________________
+58 ;; ___ Abdominal pain and/or colic pain
+59 ;; If checked, describe: ________________________________________________
+60 ;; ___ Diarrhea
+61 ;; If checked, describe: ________________________________________________
+62 ;; ___ Alternating diarrhea and constipation
+63 ;; If checked, describe: ________________________________________________
+64 ;; ___ Abdominal distension
+65 ;; If checked, describe: ________________________________________________
+66 ;; ___ Anemia
+67 ;; If checked, provide hemoglobin/hematocrit in Diagnostic testing section.
+68 ;; ___ Nausea
+69 ;; If checked, describe: ________________________________________________
+70 ;; ___ Vomiting
+71 ;; If checked, describe: ________________________________________________
+72 ;; ___ Pulling pain on attempting work or aggravated by movements of the body
+73 ;; ___ Other, describe: _____________________________________________________
+74 ;;
+75 ;; 4. Weight loss
+76 ;; Does the Veteran have weight loss or inability to gain weight attributable to
+77 ;; intestinal surgery?
+78 ;; ___ Yes ___ No
+79 ;; If yes, complete the following section:
+80 ;;
+81 ;; a. Provide Veteran's baseline weight: _______ and current weight: _______
+82 ;; (For VA purposes, baseline weight is the average weight for 2-year period
+83 ;; preceding onset of disease)
+84 ;;
+85 ;; b. Has the Veteran's weight loss been sustained for 3 months or longer?
+86 ;; ___ Yes ___ No
+87 ;;
+88 ;; c. Has the Veteran been unable to regain weight despite appropriate therapy?
+89 ;; ___ Yes ___ No
+90 ;;^TOF^
+91 ;; 5. Absorption and nutrition
+92 ;; Does the Veteran have any interference with absorption and nutrition
+93 ;; attributable to resection of the small intestine?
+94 ;; ___ Yes ___ No ___ not applicable
+95 ;; If yes, does this cause impairment of health objectively supported by
+96 ;; examination findings including definite and/or material weight loss?
+97 ;; ___ Yes ___ No
+98 ;; If yes, is impairment of health severe?
+99 ;; ___ Yes ___ No
+100 ;; Indicate severity of interference with absorption and nutrition:
+101 ;; ___ Definite ___ Marked
+102 ;;
+103 ;; 6. Ostomy
+104 ;; Did the Veteran's intestinal condition require an ileostomy or colostomy?
+105 ;; ___ Yes ___ No
+106 ;; If yes, describe: ___________________________________________________________
+107 ;;
+108 ;; 7. Fistula
+109 ;; Does the Veteran now have or has he or she ever had a persistent intestinal
+110 ;; fistula attributable to a surgical intestinal condition?
+111 ;; ___ Yes ___ No
+112 ;; If yes, does the Veteran have fecal discharge attributable to this?
+113 ;; ___ Yes ___ No
+114 ;; If yes, indicate the severity and frequency of fecal discharge (check all
+115 ;; that apply):
+116 ;; ___ Slight
+117 ;; ___ Copious
+118 ;; ___ Infrequent
+119 ;; ___ Frequent
+120 ;; ___ Constant
+121 ;; ___ Other, describe: _____________________________________________________
+122 ;;
+123 ;; 8. Other pertinent physical findings, complications, conditions, signs and/or
+124 ;; symptoms
+125 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+126 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+127 ;; section above?
+128 ;; ___ Yes ___ No
+129 ;; If yes, are any of the scars painful and/or unstable, or is the total area of
+130 ;; all related scars greater than 39 square cm (6 square inches)?
+131 ;; ___ Yes ___ No
+132 ;; If yes, also complete a Scars Questionnaire.
+133 ;;
+134 ;; b. Does the Veteran have any other pertinent physical findings,
+135 ;; complications, conditions, signs and/or symptoms related to any conditions
+136 ;; listed in the Diagnosis section above?
+137 ;; ___ Yes ___ No
+138 ;; If yes, describe (brief summary): ___________________________________________
+139 ;;^TOF^
+140 ;; 9. Diagnostic testing
+141 ;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has
+142 ;; been performed and reflects the Veteran's current condition, no further
+143 ;; studies or testing are required for this examination.
+144 ;;
+145 ;; a. Has laboratory testing been performed?
+146 ;; ___ Yes ___ No
+147 ;; If yes, check all that apply:
+148 ;; ___ CBC (if anemia due to any intestinal condition is suspected or present)
+149 ;; Date of test: ___________
+150 ;; Hemoglobin: ______ Hematocrit: _______
+151 ;; White blood cell count: ______ Platelets: _____
+152 ;; ___ Other, specify: ______ Date of test: ___________ Results: __________
+153 ;;
+154 ;; b. Have imaging studies or diagnostic procedures been performed and are the
+155 ;; results available?
+156 ;; ___ Yes ___ No
+157 ;; If yes, provide type of test or procedure, date and results (brief summary):
+158 ;; _____________________________________________________________________________
+159 ;;
+160 ;; c. Are there any other significant diagnostic test findings and/or results?
+161 ;; ___ Yes ___ No
+162 ;; If yes, provide type of test or procedure, date and results (brief summary):
+163 ;; _____________________________________________________________________________
+164 ;;
+165 ;; 10. Functional impact
+166 ;; Do any of the Veteran's intestinal surgery residuals impact his or her
+167 ;; ability to work?
+168 ;; ___ Yes ___ No
+169 ;; If yes, describe the impact of each of the Veteran's intestinal surgery
+170 ;; residuals, including any ongoing symptoms of original cause of surgery that
+171 ;; may be hard to distinguish from post-surgical residuals, providing one or
+172 ;; more examples: ______________________________________________________________
+173 ;;
+174 ;; 11. Remarks,if any: _________________________________________________________
+175 ;;
+176 ;; _____________________________________________________________________________
+177 ;;
+178 ;; Physician signature: _____________________________________ Date: ____________
+179 ;;
+180 ;; Physician printed name: __________________________________
+181 ;;
+182 ;; Medical license #: __________________
+183 ;;
+184 ;; Physician address: __________________________________________________________
+185 ;;
+186 ;; Phone: _____________________ Fax: _____________________
+187 ;;
+188 ;; NOTE: VA may request additional medical information, including additional
+189 ;; examinations if necessary to complete VA's review of the Veteran's application.
+190 ;;^END^
+191 QUIT
