Routine: DVBCQIS2

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^

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQIS2   9241     printed  Feb 18, 2025@23:13:22                                                                                                                                                                                                    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

DVBCQIS2.m