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Routine: DVBCQKC2

DVBCQKC2.m

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  1. DVBCQKC2 ;;ALB-CIOFO/ECF - KIDNEY CONDITIONS QUESTIONNAIRE ; 2/15/2010
  1.  ;;2.7;AMIE;**163**;Apr 10, 1995;Build 5
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1.  ;; disability benefits.  VA will consider the information you provide on this
  1.  ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;;
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with a kidney
  1.  ;; condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If no, provide rationale (e.g., Veteran has never had any known kidney
  1.  ;; condition(s)):_______________________________________________________________
  1.  ;;
  1.  ;; If yes, indicate diagnoses: (check all that apply)
  1.  ;; ___ Diabetic nephropathy      ICD Code: ______   Date of Diagnosis: _________
  1.  ;; ___ Glomerulonephritis        ICD Code: ______   Date of Diagnosis: _________
  1.  ;; ___ Hydronephrosis            ICD Code: ______   Date of Diagnosis: _________
  1.  ;; ___ Interstitial nephritis    ICD Code: ______   Date of Diagnosis: _________
  1.  ;; ___ Kidney transplant         ICD Code: ______   Date of Diagnosis: _________
  1.  ;; ___ Nephrosclerosis           ICD Code: ______   Date of Diagnosis: _________
  1.  ;; ___ Nephrolithiasis           ICD Code: ______   Date of Diagnosis: _________
  1.  ;; ___ Renal artery stenosis     ICD Code: ______   Date of Diagnosis: _________
  1.  ;; ___ Ureterolithiasis          ICD Code: ______   Date of Diagnosis: _________
  1.  ;; ___ Neoplasm of the kidney
  1.  ;;                               ICD Code: ______   Date of Diagnosis: _________
  1.  ;; ___ Other kidney condition (specify diagnosis, providing only diagnoses
  1.  ;;     that pertain to kidney conditions.)
  1.  ;;
  1.  ;;     Other diagnosis #1: ______________
  1.  ;;     ICD code: ________________________
  1.  ;;     Date of diagnosis: _______________
  1.  ;;
  1.  ;;     Other diagnosis #2: ______________
  1.  ;;     ICD code: ________________________
  1.  ;;     Date of diagnosis: _______________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to kidney conditions, list
  1.  ;; using above format: _________________________________________________________
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;;
  1.  ;; Describe the history (including cause, onset and course) of the Veteran's
  1.  ;; kidney condition: ___________________________________________________________
  1.  ;;^TOF^
  1.  ;; 3. Renal dysfunction
  1.  ;;
  1.  ;; a. Does the Veteran have renal dysfunction?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, does the Veteran require regular dialysis?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; b. Does the Veteran have any signs or symptoms due to renal dysfunction?
  1.  ;; ___ Yes   ___ No
  1.  ;; 
  1.  ;; If yes,check all that apply:
  1.  ;;
  1.  ;;    ___ Proteinuria (albuminuria)
  1.  ;;        If checked, indicate frequency: (check all that apply)
  1.  ;;              ___ Recurring   ___ Constant   ___ Persistent
  1.  ;;    ___ Edema (due to renal dysfunction)
  1.  ;;        If checked, indicate frequency: (check all that apply)
  1.  ;;              ___ Some   ___ Transient   ___ Slight   ___ Persistent
  1.  ;;    ___ Anorexia (due to renal dysfunction)
  1.  ;;    ___ Weight loss (due to renal dysfunction)
  1.  ;;        If checked, provide baseline weight (average weight for 2-year period
  1.  ;;        preceding onset of disease): ____________
  1.  ;;        Provide current weight: _________________
  1.  ;;    ___ Generalized poor health due to renal dysfunction
  1.  ;;    ___ Lethargy due to renal dysfunction
  1.  ;;    ___ Weakness due to renal dysfunction
  1.  ;;    ___ Limitation of exertion due to renal dysfunction
  1.  ;;    ___ Able to perform only sedentary activity, due to persistent edema
  1.  ;;        caused by renal dysfunction
  1.  ;;    ___ Markedly decreased function other organ systems, especially the
  1.  ;;        cardiovascular system, caused by renal dysfunction
  1.  ;;           If checked, describe: _____________________________________________
  1.  ;;
  1.  ;; c. Does the Veteran have hypertension and/or heart disease due to renal
  1.  ;; dysfunction or caused by any kidney condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, also complete the Hypertension and/or Heart Disease Questionnaire
  1.  ;; as appropriate.
  1.  ;;^TOF^
  1.  ;; 4. Urolithiasis
  1.  ;;
  1.  ;; a. Does the Veteran have kidney, ureteral or bladder calculi?
  1.  ;; ___ Yes   ___  No
  1.  ;;
  1.  ;; If yes, indicate location (check all that apply)
  1.  ;;   ___ Kidney   ___ Ureter   ___Bladder
  1.  ;;
  1.  ;; If the Veteran has urolithiasis, complete the following:
  1.  ;;
  1.  ;; b. Has the Veteran had treatment for recurrent stone formation in the kidney,
  1.  ;; ureter or bladder?
  1.  ;; ___ Yes   ___  No
  1.  ;;
  1.  ;; If yes, indicate treatment: (check all that apply)
  1.  ;;   ___ Diet therapy
  1.  ;;       If checked, specify diet and dates of use: ____________________________
  1.  ;;   ___ Drug therapy
  1.  ;;       If checked, list medication and dates of use: _________________________
  1.  ;;   ___ Invasive or non-invasive procedures
  1.  ;;       If checked, indicate average number of times per year invasive or
  1.  ;;       non-invasive procedures were required:
  1.  ;;       ___ 0 to 1 per year    ___ 2 per year    ___ > 2 per year
  1.  ;;       Date and facility of most recent invasive or non-invasive procedure:
  1.  ;;       _______________________________________________________________________
  1.  ;;
  1.  ;; c. Does the Veteran have signs or symptoms due to urolithiasis?
  1.  ;; ___ Yes   ___  No
  1.  ;;
  1.  ;; If yes, indicate severity (check all that apply)
  1.  ;;   ___ No symptoms or attacks of colic
  1.  ;;   ___ Occasional attacks of colic
  1.  ;;   ___ Frequent attacks of colic
  1.  ;;   ___ Causing voiding dysfunction
  1.  ;;   ___ Requires catheter drainage
  1.  ;;   ___ Causing infection (pyonephrosis)
  1.  ;;   ___ Causing hydronephrosis
  1.  ;;   ___ Causing impaired kidney function
  1.  ;;   ___ Other, describe: ______________________________________________________
  1.  ;;^TOF^
  1.  ;; 5. Urinary tract/kidney infection
  1.  ;;
  1.  ;; Does the Veteran have a history of recurrent symptomatic urinary tract or
  1.  ;; kidney infections?
  1.  ;; ___ Yes   ___  No
  1.  ;;
  1.  ;; If yes, provide etiology: ___________________________________________________
  1.  ;;
  1.  ;; If the Veteran has had recurrent symptomatic urinary tract or kidney
  1.  ;; infections, indicate all treatment modalities that apply:
  1.  ;;   ___ No treatment
  1.  ;;   ___ Long-term drug therapy
  1.  ;;       If checked, list medications used and indicate dates for courses of
  1.  ;;       treatment over the past 12 months: ____________________________________
  1.  ;;   ___ Hospitalization
  1.  ;;       If checked, indicate frequency of hospitalization:
  1.  ;;          ___ 1 or 2 per year
  1.  ;;          ___ > 2 per year
  1.  ;;   ___ Drainage
  1.  ;;         If checked, indicate dates when drainage performed over past 12
  1.  ;;         months: _______________________________
  1.  ;;   ___ Continuous intensive management
  1.  ;;         If checked, indicate types of treatment and medications used over
  1.  ;;         past 12 months: _______________________
  1.  ;;   ___ Intermittent intensive management
  1.  ;;         If checked, indicate types of treatment and medications used over
  1.  ;;         past 12 months: _______________________
  1.  ;;   ___ Other, describe: ________________________
  1.  ;;
  1.  ;; 6. Kidney transplant or removal
  1.  ;;
  1.  ;; a. Has the Veteran had a kidney removed?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide reason:
  1.  ;;    ___ Kidney donation
  1.  ;;    ___ Due to disease
  1.  ;;    ___ Due to trauma or injury
  1.  ;;    ___ Other, describe: ______________________
  1.  ;;
  1.  ;; b. Has the Veteran had a kidney transplant?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, date of admission: ___________________
  1.  ;; Date of discharge: ___________________________
  1.  ;;^TOF^
  1.  ;; 7. Tumors and neoplasms
  1.  ;;
  1.  ;; a.  Does the Veteran have a benign or malignant neoplasm or metastases
  1.  ;; related to any of the diagnoses in the Diagnosis section?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, complete the following:
  1.  ;;
  1.  ;; b. Is the neoplasm
  1.  ;; ___ Benign    ___ Malignant
  1.  ;;
  1.  ;; c. Has the Veteran completed treatment or is the Veteran currently undergoing
  1.  ;; treatment for a benign or malignant neoplasm or metastases?
  1.  ;; ___ Yes   ___ No; watchful waiting
  1.  ;;
  1.  ;;    If yes, indicate type of treatment the Veteran is currently undergoing or
  1.  ;;    has completed (check all that apply):
  1.  ;;    ___ Treatment completed; currently in watchful waiting status
  1.  ;;    ___ Surgery
  1.  ;;        If checked, describe: ________________________________________________
  1.  ;;        Date(s) of surgery: _________
  1.  ;;    ___ Radiation therapy
  1.  ;;        Date of most recent treatment: ___________
  1.  ;;        Date of completion of treatment or anticipated date of
  1.  ;;        completion: _________________
  1.  ;;    ___ Antineoplastic chemotherapy
  1.  ;;        Date of most recent treatment: ___________
  1.  ;;        Date of completion of treatment or anticipated date of
  1.  ;;        completion: _________________
  1.  ;;    ___ Other therapeutic procedure
  1.  ;;        If checked, describe procedure: ______________________________________
  1.  ;;        Date of most recent procedure: ___________
  1.  ;;    ___ Other therapeutic treatment
  1.  ;;        If checked, describe treatment: ______________________________________
  1.  ;;        Date of completion of treatment or anticipated date of
  1.  ;;        completion: _________________
  1.  ;;
  1.  ;; d. Does the Veteran currently have any residual conditions or complications
  1.  ;; due to the neoplasm (including metastases) or its treatment, other than those
  1.  ;; already documented in the report above?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, list residual conditions and complications (brief summary): _________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; e. If there are additional benign or malignant neoplasms or metastases
  1.  ;; related to any of the diagnoses in the Diagnosis section, describe using the
  1.  ;; above format: _______________________________________________________________
  1.  ;;^TOF^
  1.  ;; 8. Other pertinent physical findings, complications, conditions, signs and/or
  1.  ;; symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?
  1.  ;; ___ Yes   ___ No
  1.  ;;    If yes, are any of the scars painful and/or unstable, or is the total area
  1.  ;;    of all related scars greater than 39 square cm (6 square inches)?
  1.  ;;    ___ Yes   ___ No
  1.  ;;    If yes, also complete a Scars Questionnaire.
  1.  ;; 
  1.  ;; b. Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs or symptoms?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe (brief summary): ___________________________________________
  1.  ;;
  1.  ;; 9. Diagnostic testing
  1.  ;;
  1.  ;; NOTE: If laboratory test results are in the medical record and reflect the
  1.  ;; Veteran's current renal function, repeat testing is not required.
  1.  ;;
  1.  ;; a. Has the Veteran had laboratory or other diagnostic studies performed?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide most recent results, if available:
  1.  ;;
  1.  ;; b. Laboratory studies
  1.  ;;    ___ BUN:                        Date: ___________   Result: ______________
  1.  ;;    ___ Creatinine:                 Date: ___________   Result: ______________
  1.  ;;    ___ EGFR:                       Date: ___________   Result: ______________
  1.  ;;
  1.  ;; c. Urinalysis:
  1.  ;;    ___ Hyaline casts:              Date: ___________   Result: ______________
  1.  ;;    ___ Granular casts:             Date: ___________   Result: ______________
  1.  ;;    ___ RBC's/HPF:                  Date: ___________   Result: ______________
  1.  ;;    ___ Protein (albumin):          Date: ___________   Result: ______________
  1.  ;;    ___ Spot urine for
  1.  ;;        protein/creatinine ratio:   Date: ___________   Result: ______________
  1.  ;;    ___ 24 hour protein (albumin):  Date: ___________   Result: ______________
  1.  ;;
  1.  ;; d. Urine microalbumin:             Date: ___________   Result: ______________
  1.  ;;
  1.  ;; e. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; _____________________________________________________________________________
  1.  ;;^TOF^
  1.  ;; 10. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's kidney condition(s), including neoplasms, if any, impact
  1.  ;; his or her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe impact of each of the Veteran's kidney conditions, providing
  1.  ;; one or more examples: _______________________________________________________
  1.  ;;
  1.  ;; 11. Remarks, if any: ________________________________________________________
  1.  ;;
  1.  ;; Physician signature: _____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: __________________________________ Phone: ___________
  1.  ;;
  1.  ;; Medical license #: _______________________________________ Fax: _____________
  1.  ;;
  1.  ;; Physician address: __________________________________________________________
  1.  ;;
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's
  1.  ;; application.
  1.  ;;^END^
  1.  Q