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Routine: DVBCQIS2

DVBCQIS2.m

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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