DVBCQKC2 ;;ALB-CIOFO/ECF - KIDNEY CONDITIONS QUESTIONNAIRE ; 2/15/2010
;;2.7;AMIE;**163**;Apr 10, 1995;Build 5
;
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 a kidney
;; condition?
;; ___ Yes ___ No
;;
;; If no, provide rationale (e.g., Veteran has never had any known kidney
;; condition(s)):_______________________________________________________________
;;
;; If yes, indicate diagnoses: (check all that apply)
;; ___ Diabetic nephropathy ICD Code: ______ Date of Diagnosis: _________
;; ___ Glomerulonephritis ICD Code: ______ Date of Diagnosis: _________
;; ___ Hydronephrosis ICD Code: ______ Date of Diagnosis: _________
;; ___ Interstitial nephritis ICD Code: ______ Date of Diagnosis: _________
;; ___ Kidney transplant ICD Code: ______ Date of Diagnosis: _________
;; ___ Nephrosclerosis ICD Code: ______ Date of Diagnosis: _________
;; ___ Nephrolithiasis ICD Code: ______ Date of Diagnosis: _________
;; ___ Renal artery stenosis ICD Code: ______ Date of Diagnosis: _________
;; ___ Ureterolithiasis ICD Code: ______ Date of Diagnosis: _________
;; ___ Neoplasm of the kidney
;; ICD Code: ______ Date of Diagnosis: _________
;; ___ Other kidney condition (specify diagnosis, providing only diagnoses
;; that pertain to kidney 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 kidney conditions, list
;; using above format: _________________________________________________________
;;
;; 2. Medical history
;;
;; Describe the history (including cause, onset and course) of the Veteran's
;; kidney condition: ___________________________________________________________
;;^TOF^
;; 3. Renal dysfunction
;;
;; a. Does the Veteran have renal dysfunction?
;; ___ Yes ___ No
;;
;; If yes, does the Veteran require regular dialysis?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have any signs or symptoms due to renal dysfunction?
;; ___ Yes ___ No
;;
;; If yes,check all that apply:
;;
;; ___ Proteinuria (albuminuria)
;; If checked, indicate frequency: (check all that apply)
;; ___ Recurring ___ Constant ___ Persistent
;; ___ Edema (due to renal dysfunction)
;; If checked, indicate frequency: (check all that apply)
;; ___ Some ___ Transient ___ Slight ___ Persistent
;; ___ Anorexia (due to renal dysfunction)
;; ___ Weight loss (due to renal dysfunction)
;; If checked, provide baseline weight (average weight for 2-year period
;; preceding onset of disease): ____________
;; Provide current weight: _________________
;; ___ Generalized poor health due to renal dysfunction
;; ___ Lethargy due to renal dysfunction
;; ___ Weakness due to renal dysfunction
;; ___ Limitation of exertion due to renal dysfunction
;; ___ Able to perform only sedentary activity, due to persistent edema
;; caused by renal dysfunction
;; ___ Markedly decreased function other organ systems, especially the
;; cardiovascular system, caused by renal dysfunction
;; If checked, describe: _____________________________________________
;;
;; c. Does the Veteran have hypertension and/or heart disease due to renal
;; dysfunction or caused by any kidney condition?
;; ___ Yes ___ No
;;
;; If yes, also complete the Hypertension and/or Heart Disease Questionnaire
;; as appropriate.
;;^TOF^
;; 4. Urolithiasis
;;
;; a. Does the Veteran have kidney, ureteral or bladder calculi?
;; ___ Yes ___ No
;;
;; If yes, indicate location (check all that apply)
;; ___ Kidney ___ Ureter ___Bladder
;;
;; If the Veteran has urolithiasis, complete the following:
;;
;; b. Has the Veteran had treatment for recurrent stone formation in the kidney,
;; ureter or bladder?
;; ___ Yes ___ No
;;
;; If yes, indicate treatment: (check all that apply)
;; ___ Diet therapy
;; If checked, specify diet and dates of use: ____________________________
;; ___ Drug therapy
;; If checked, list medication and dates of use: _________________________
;; ___ Invasive or non-invasive procedures
;; If checked, indicate average number of times per year invasive or
;; non-invasive procedures were required:
;; ___ 0 to 1 per year ___ 2 per year ___ > 2 per year
;; Date and facility of most recent invasive or non-invasive procedure:
;; _______________________________________________________________________
;;
;; c. Does the Veteran have signs or symptoms due to urolithiasis?
;; ___ Yes ___ No
;;
;; If yes, indicate severity (check all that apply)
;; ___ No symptoms or attacks of colic
;; ___ Occasional attacks of colic
;; ___ Frequent attacks of colic
;; ___ Causing voiding dysfunction
;; ___ Requires catheter drainage
;; ___ Causing infection (pyonephrosis)
;; ___ Causing hydronephrosis
;; ___ Causing impaired kidney function
;; ___ Other, describe: ______________________________________________________
;;^TOF^
;; 5. Urinary tract/kidney infection
;;
;; Does the Veteran have a history of recurrent symptomatic urinary tract or
;; kidney infections?
;; ___ Yes ___ No
;;
;; If yes, provide etiology: ___________________________________________________
;;
;; If the Veteran has had recurrent symptomatic urinary tract or kidney
;; infections, indicate all treatment modalities that apply:
;; ___ No treatment
;; ___ Long-term drug therapy
;; If checked, list medications used and indicate dates for courses of
;; treatment over the past 12 months: ____________________________________
;; ___ Hospitalization
;; If checked, indicate frequency of hospitalization:
;; ___ 1 or 2 per year
;; ___ > 2 per year
;; ___ Drainage
;; If checked, indicate dates when drainage performed over past 12
;; months: _______________________________
;; ___ Continuous intensive management
;; If checked, indicate types of treatment and medications used over
;; past 12 months: _______________________
;; ___ Intermittent intensive management
;; If checked, indicate types of treatment and medications used over
;; past 12 months: _______________________
;; ___ Other, describe: ________________________
;;
;; 6. Kidney transplant or removal
;;
;; a. Has the Veteran had a kidney removed?
;; ___ Yes ___ No
;;
;; If yes, provide reason:
;; ___ Kidney donation
;; ___ Due to disease
;; ___ Due to trauma or injury
;; ___ Other, describe: ______________________
;;
;; b. Has the Veteran had a kidney transplant?
;; ___ Yes ___ No
;;
;; If yes, date of admission: ___________________
;; Date of discharge: ___________________________
;;^TOF^
;; 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: _________________
;; ___ 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: _______________________________________________________________
;;^TOF^
;; 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 or symptoms?
;; ___ Yes ___ No
;;
;; If yes, describe (brief summary): ___________________________________________
;;
;; 9. Diagnostic testing
;;
;; NOTE: If laboratory test results are in the medical record and reflect the
;; Veteran's current renal function, repeat testing is not required.
;;
;; a. Has the Veteran had laboratory or other diagnostic studies performed?
;; ___ Yes ___ No
;;
;; If yes, provide most recent results, if available:
;;
;; b. Laboratory studies
;; ___ BUN: Date: ___________ Result: ______________
;; ___ Creatinine: Date: ___________ Result: ______________
;; ___ EGFR: Date: ___________ Result: ______________
;;
;; c. Urinalysis:
;; ___ Hyaline casts: Date: ___________ Result: ______________
;; ___ Granular casts: Date: ___________ Result: ______________
;; ___ RBC's/HPF: Date: ___________ Result: ______________
;; ___ Protein (albumin): Date: ___________ Result: ______________
;; ___ Spot urine for
;; protein/creatinine ratio: Date: ___________ Result: ______________
;; ___ 24 hour protein (albumin): Date: ___________ Result: ______________
;;
;; d. Urine microalbumin: Date: ___________ Result: ______________
;;
;; e. 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):
;; _____________________________________________________________________________
;;^TOF^
;; 10. Functional impact
;;
;; Does the Veteran's kidney condition(s), including neoplasms, if any, impact
;; his or her ability to work?
;; ___ Yes ___ No
;;
;; If yes, describe impact of each of the Veteran's kidney 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[HDVBCQKC2 13273 printed Apr 09, 2024@20:56:10 Page 2
DVBCQKC2 ;;ALB-CIOFO/ECF - KIDNEY CONDITIONS QUESTIONNAIRE ; 2/15/2010
+1 ;;2.7;AMIE;**163**;Apr 10, 1995;Build 5
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+3 ;; disability benefits. VA will consider the information you provide on this
+4 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+5 ;;
+6 ;; 1. Diagnosis
+7 ;;
+8 ;; Does the Veteran now have or has he/she ever been diagnosed with a kidney
+9 ;; condition?
+10 ;; ___ Yes ___ No
+11 ;;
+12 ;; If no, provide rationale (e.g., Veteran has never had any known kidney
+13 ;; condition(s)):_______________________________________________________________
+14 ;;
+15 ;; If yes, indicate diagnoses: (check all that apply)
+16 ;; ___ Diabetic nephropathy ICD Code: ______ Date of Diagnosis: _________
+17 ;; ___ Glomerulonephritis ICD Code: ______ Date of Diagnosis: _________
+18 ;; ___ Hydronephrosis ICD Code: ______ Date of Diagnosis: _________
+19 ;; ___ Interstitial nephritis ICD Code: ______ Date of Diagnosis: _________
+20 ;; ___ Kidney transplant ICD Code: ______ Date of Diagnosis: _________
+21 ;; ___ Nephrosclerosis ICD Code: ______ Date of Diagnosis: _________
+22 ;; ___ Nephrolithiasis ICD Code: ______ Date of Diagnosis: _________
+23 ;; ___ Renal artery stenosis ICD Code: ______ Date of Diagnosis: _________
+24 ;; ___ Ureterolithiasis ICD Code: ______ Date of Diagnosis: _________
+25 ;; ___ Neoplasm of the kidney
+26 ;; ICD Code: ______ Date of Diagnosis: _________
+27 ;; ___ Other kidney condition (specify diagnosis, providing only diagnoses
+28 ;; that pertain to kidney 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 kidney conditions, list
+39 ;; using above format: _________________________________________________________
+40 ;;
+41 ;; 2. Medical history
+42 ;;
+43 ;; Describe the history (including cause, onset and course) of the Veteran's
+44 ;; kidney condition: ___________________________________________________________
+45 ;;^TOF^
+46 ;; 3. Renal dysfunction
+47 ;;
+48 ;; a. Does the Veteran have renal dysfunction?
+49 ;; ___ Yes ___ No
+50 ;;
+51 ;; If yes, does the Veteran require regular dialysis?
+52 ;; ___ Yes ___ No
+53 ;;
+54 ;; b. Does the Veteran have any signs or symptoms due to renal dysfunction?
+55 ;; ___ Yes ___ No
+56 ;;
+57 ;; If yes,check all that apply:
+58 ;;
+59 ;; ___ Proteinuria (albuminuria)
+60 ;; If checked, indicate frequency: (check all that apply)
+61 ;; ___ Recurring ___ Constant ___ Persistent
+62 ;; ___ Edema (due to renal dysfunction)
+63 ;; If checked, indicate frequency: (check all that apply)
+64 ;; ___ Some ___ Transient ___ Slight ___ Persistent
+65 ;; ___ Anorexia (due to renal dysfunction)
+66 ;; ___ Weight loss (due to renal dysfunction)
+67 ;; If checked, provide baseline weight (average weight for 2-year period
+68 ;; preceding onset of disease): ____________
+69 ;; Provide current weight: _________________
+70 ;; ___ Generalized poor health due to renal dysfunction
+71 ;; ___ Lethargy due to renal dysfunction
+72 ;; ___ Weakness due to renal dysfunction
+73 ;; ___ Limitation of exertion due to renal dysfunction
+74 ;; ___ Able to perform only sedentary activity, due to persistent edema
+75 ;; caused by renal dysfunction
+76 ;; ___ Markedly decreased function other organ systems, especially the
+77 ;; cardiovascular system, caused by renal dysfunction
+78 ;; If checked, describe: _____________________________________________
+79 ;;
+80 ;; c. Does the Veteran have hypertension and/or heart disease due to renal
+81 ;; dysfunction or caused by any kidney condition?
+82 ;; ___ Yes ___ No
+83 ;;
+84 ;; If yes, also complete the Hypertension and/or Heart Disease Questionnaire
+85 ;; as appropriate.
+86 ;;^TOF^
+87 ;; 4. Urolithiasis
+88 ;;
+89 ;; a. Does the Veteran have kidney, ureteral or bladder calculi?
+90 ;; ___ Yes ___ No
+91 ;;
+92 ;; If yes, indicate location (check all that apply)
+93 ;; ___ Kidney ___ Ureter ___Bladder
+94 ;;
+95 ;; If the Veteran has urolithiasis, complete the following:
+96 ;;
+97 ;; b. Has the Veteran had treatment for recurrent stone formation in the kidney,
+98 ;; ureter or bladder?
+99 ;; ___ Yes ___ No
+100 ;;
+101 ;; If yes, indicate treatment: (check all that apply)
+102 ;; ___ Diet therapy
+103 ;; If checked, specify diet and dates of use: ____________________________
+104 ;; ___ Drug therapy
+105 ;; If checked, list medication and dates of use: _________________________
+106 ;; ___ Invasive or non-invasive procedures
+107 ;; If checked, indicate average number of times per year invasive or
+108 ;; non-invasive procedures were required:
+109 ;; ___ 0 to 1 per year ___ 2 per year ___ > 2 per year
+110 ;; Date and facility of most recent invasive or non-invasive procedure:
+111 ;; _______________________________________________________________________
+112 ;;
+113 ;; c. Does the Veteran have signs or symptoms due to urolithiasis?
+114 ;; ___ Yes ___ No
+115 ;;
+116 ;; If yes, indicate severity (check all that apply)
+117 ;; ___ No symptoms or attacks of colic
+118 ;; ___ Occasional attacks of colic
+119 ;; ___ Frequent attacks of colic
+120 ;; ___ Causing voiding dysfunction
+121 ;; ___ Requires catheter drainage
+122 ;; ___ Causing infection (pyonephrosis)
+123 ;; ___ Causing hydronephrosis
+124 ;; ___ Causing impaired kidney function
+125 ;; ___ Other, describe: ______________________________________________________
+126 ;;^TOF^
+127 ;; 5. Urinary tract/kidney infection
+128 ;;
+129 ;; Does the Veteran have a history of recurrent symptomatic urinary tract or
+130 ;; kidney infections?
+131 ;; ___ Yes ___ No
+132 ;;
+133 ;; If yes, provide etiology: ___________________________________________________
+134 ;;
+135 ;; If the Veteran has had recurrent symptomatic urinary tract or kidney
+136 ;; infections, indicate all treatment modalities that apply:
+137 ;; ___ No treatment
+138 ;; ___ Long-term drug therapy
+139 ;; If checked, list medications used and indicate dates for courses of
+140 ;; treatment over the past 12 months: ____________________________________
+141 ;; ___ Hospitalization
+142 ;; If checked, indicate frequency of hospitalization:
+143 ;; ___ 1 or 2 per year
+144 ;; ___ > 2 per year
+145 ;; ___ Drainage
+146 ;; If checked, indicate dates when drainage performed over past 12
+147 ;; months: _______________________________
+148 ;; ___ Continuous intensive management
+149 ;; If checked, indicate types of treatment and medications used over
+150 ;; past 12 months: _______________________
+151 ;; ___ Intermittent intensive management
+152 ;; If checked, indicate types of treatment and medications used over
+153 ;; past 12 months: _______________________
+154 ;; ___ Other, describe: ________________________
+155 ;;
+156 ;; 6. Kidney transplant or removal
+157 ;;
+158 ;; a. Has the Veteran had a kidney removed?
+159 ;; ___ Yes ___ No
+160 ;;
+161 ;; If yes, provide reason:
+162 ;; ___ Kidney donation
+163 ;; ___ Due to disease
+164 ;; ___ Due to trauma or injury
+165 ;; ___ Other, describe: ______________________
+166 ;;
+167 ;; b. Has the Veteran had a kidney transplant?
+168 ;; ___ Yes ___ No
+169 ;;
+170 ;; If yes, date of admission: ___________________
+171 ;; Date of discharge: ___________________________
+172 ;;^TOF^
+173 ;; 7. Tumors and neoplasms
+174 ;;
+175 ;; a. Does the Veteran have a benign or malignant neoplasm or metastases
+176 ;; related to any of the diagnoses in the Diagnosis section?
+177 ;; ___ Yes ___ No
+178 ;;
+179 ;; If yes, complete the following:
+180 ;;
+181 ;; b. Is the neoplasm
+182 ;; ___ Benign ___ Malignant
+183 ;;
+184 ;; c. Has the Veteran completed treatment or is the Veteran currently undergoing
+185 ;; treatment for a benign or malignant neoplasm or metastases?
+186 ;; ___ Yes ___ No; watchful waiting
+187 ;;
+188 ;; If yes, indicate type of treatment the Veteran is currently undergoing or
+189 ;; has completed (check all that apply):
+190 ;; ___ Treatment completed; currently in watchful waiting status
+191 ;; ___ Surgery
+192 ;; If checked, describe: ________________________________________________
+193 ;; Date(s) of surgery: _________
+194 ;; ___ Radiation therapy
+195 ;; Date of most recent treatment: ___________
+196 ;; Date of completion of treatment or anticipated date of
+197 ;; completion: _________________
+198 ;; ___ Antineoplastic chemotherapy
+199 ;; Date of most recent treatment: ___________
+200 ;; Date of completion of treatment or anticipated date of
+201 ;; completion: _________________
+202 ;; ___ Other therapeutic procedure
+203 ;; If checked, describe procedure: ______________________________________
+204 ;; Date of most recent procedure: ___________
+205 ;; ___ Other therapeutic treatment
+206 ;; If checked, describe treatment: ______________________________________
+207 ;; Date of completion of treatment or anticipated date of
+208 ;; completion: _________________
+209 ;;
+210 ;; d. Does the Veteran currently have any residual conditions or complications
+211 ;; due to the neoplasm (including metastases) or its treatment, other than those
+212 ;; already documented in the report above?
+213 ;; ___ Yes ___ No
+214 ;;
+215 ;; If yes, list residual conditions and complications (brief summary): _________
+216 ;; _____________________________________________________________________________
+217 ;;
+218 ;; e. If there are additional benign or malignant neoplasms or metastases
+219 ;; related to any of the diagnoses in the Diagnosis section, describe using the
+220 ;; above format: _______________________________________________________________
+221 ;;^TOF^
+222 ;; 8. Other pertinent physical findings, complications, conditions, signs and/or
+223 ;; symptoms
+224 ;;
+225 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+226 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+227 ;; section above?
+228 ;; ___ Yes ___ No
+229 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+230 ;; of all related scars greater than 39 square cm (6 square inches)?
+231 ;; ___ Yes ___ No
+232 ;; If yes, also complete a Scars Questionnaire.
+233 ;;
+234 ;; b. Does the Veteran have any other pertinent physical findings,
+235 ;; complications, conditions, signs or symptoms?
+236 ;; ___ Yes ___ No
+237 ;;
+238 ;; If yes, describe (brief summary): ___________________________________________
+239 ;;
+240 ;; 9. Diagnostic testing
+241 ;;
+242 ;; NOTE: If laboratory test results are in the medical record and reflect the
+243 ;; Veteran's current renal function, repeat testing is not required.
+244 ;;
+245 ;; a. Has the Veteran had laboratory or other diagnostic studies performed?
+246 ;; ___ Yes ___ No
+247 ;;
+248 ;; If yes, provide most recent results, if available:
+249 ;;
+250 ;; b. Laboratory studies
+251 ;; ___ BUN: Date: ___________ Result: ______________
+252 ;; ___ Creatinine: Date: ___________ Result: ______________
+253 ;; ___ EGFR: Date: ___________ Result: ______________
+254 ;;
+255 ;; c. Urinalysis:
+256 ;; ___ Hyaline casts: Date: ___________ Result: ______________
+257 ;; ___ Granular casts: Date: ___________ Result: ______________
+258 ;; ___ RBC's/HPF: Date: ___________ Result: ______________
+259 ;; ___ Protein (albumin): Date: ___________ Result: ______________
+260 ;; ___ Spot urine for
+261 ;; protein/creatinine ratio: Date: ___________ Result: ______________
+262 ;; ___ 24 hour protein (albumin): Date: ___________ Result: ______________
+263 ;;
+264 ;; d. Urine microalbumin: Date: ___________ Result: ______________
+265 ;;
+266 ;; e. Are there any other significant diagnostic test findings and/or results?
+267 ;; ___ Yes ___ No
+268 ;;
+269 ;; If yes, provide type of test or procedure, date and results (brief summary):
+270 ;; _____________________________________________________________________________
+271 ;;^TOF^
+272 ;; 10. Functional impact
+273 ;;
+274 ;; Does the Veteran's kidney condition(s), including neoplasms, if any, impact
+275 ;; his or her ability to work?
+276 ;; ___ Yes ___ No
+277 ;;
+278 ;; If yes, describe impact of each of the Veteran's kidney conditions, providing
+279 ;; one or more examples: _______________________________________________________
+280 ;;
+281 ;; 11. Remarks, if any: ________________________________________________________
+282 ;;
+283 ;; Physician signature: _____________________________________ Date: ____________
+284 ;;
+285 ;; Physician printed name: __________________________________ Phone: ___________
+286 ;;
+287 ;; Medical license #: _______________________________________ Fax: _____________
+288 ;;
+289 ;; Physician address: __________________________________________________________
+290 ;;
+291 ;; NOTE: VA may request additional medical information, including additional
+292 ;; examinations if necessary to complete VA's review of the Veteran's
+293 ;; application.
+294 ;;^END^
+295 QUIT
