Routine: DVBCQKC4

DVBCQKC4 ;;ALB-CIOFO/ECF - KIDNEY CONDITIONS QUESTIONNAIRE (V2); 6/15/2011

 ;;2.7;AMIE;**169**;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 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: _________

 ;; ___ Cholesterol emboli        ICD code: ______   Date of diagnosis: _________

 ;; ___ Cystic kidney disease     ICD code: ______   Date of diagnosis: _________

 ;; ___ Congenital kidney disorder

 ;;                               ICD code: ______   Date of diagnosis: _________

 ;; ___ Other inherited kidney disorder, specify:

 ;;                               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: ________________________________________________________

 ;;^TOF^

 ;; 2. Medical history

;;

 ;; a. Describe the history (including cause, onset and course) of the Veteran's

 ;; kidney condition (brief summary): __________________________________________

 ;; b. Does the Veteran's treatment plan include taking continuous medication

 ;; for the diagnosed condition?

 ;; ___ Yes   ___ No

 ;; List medications taken for the diagnosed condition:

 ;; ____________________________________________________________________________

;;

 ;; 3. Renal dysfunction

;;

 ;; Does the Veteran have renal dysfunction? (Evidence of renal dysfunction

 ;; includes either persistent proteinuria, hematuria or GFR < 60 cc/min/1.73m2)

 ;; ___ Yes   ___ No

 ;; If yes, complete the following section:

;;

 ;; a. 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 of other organ systems, especially the

 ;;        cardiovascular system, caused by renal dysfunction

 ;;           If checked, describe: _____________________________________________

 ;;    ___ Other, describe: _____________________________________________________

 ;;^TOF^

 ;; 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.

;;

 ;; 4. Urolithiasis

;;

 ;; Does the Veteran now have or has he/she ever had kidney, ureteral or

 ;; bladder calculi (urolithiasis)?

 ;; ___ Yes   ___  No

 ;; If yes, complete the following section:

;;

 ;; a. Indicate current/past location of calculi (check all that apply)

 ;;    ___ Kidney   ___ Ureter   ___Bladder

;;

 ;; 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 any 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, complete the following section:

;;

 ;; a. Etiology of recurrent urinary tract or kidney infections:

 ;; ____________________________________________________________________________

;;

 ;; b. Indicate all treatment modalities used for recurrent urinary tract or kidney

 ;; infections (check all 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

;;

 ;; Has the Veteran had a kidney transplant or removal?

 ;; ___ Yes   ___ No

 ;; If yes, complete the following section:

;;

 ;; 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: ______________________

 ;;^TOF^

 ;; b. Has the Veteran had a kidney transplant?

 ;; ___ Yes   ___ No

;;

 ;; If yes, date of transplant: __________________

 ;; Name of treatment facility, date of admission and date of discharge for

 ;; transplant: ________________________________________________________________

;;

 ;; 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 section:

;;

 ;; 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: _________________

 ;;^TOF^

 ;; 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: _______________________________________________________________

;;

 ;; 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. Provide

 ;; testing completed appropriate to Veteran's condition; testing indicated below

 ;; is not indicated for every kidney condition.

;;

 ;; 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: _____________

 ;;^TOF^

 ;; c. Urinalysis:

 ;;    ___ Hyaline casts:              Date: ___________   Result: _____________

 ;;    ___ Granular casts:             Date: ___________   Result: _____________

 ;;    ___ RBC's/HPF:                  Date: ___________   Result: _____________

 ;;    ___ Proteinuria (albumin):      Date: ___________   Result: _____________

 ;;    ___ Spot urine for

 ;;        protein/creatinine ratio:   Date: ___________   Result: _____________

 ;;    ___ 24 hour protein (mg/day):   Date: ___________   Result: _____________

;;

 ;; d. Spot urine microalbumin/creatinine:

 ;;                                    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):

 ;; _____________________________________________________________________________

;;

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQKC4   13607     printed  Feb 18, 2025@23:13:26                                                                                                                                                                                                   Page 2

DVBCQKC4  ;;ALB-CIOFO/ECF - KIDNEY CONDITIONS QUESTIONNAIRE (V2); 6/15/2011

 +1       ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5

 +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       ;;

 +7       ;; Does the Veteran now have or has he/she ever been diagnosed with a kidney

 +8       ;; condition?

 +9       ;; ___ Yes   ___ No

 +10      ;;

 +11      ;; If yes, indicate diagnoses: (check all that apply)

 +12      ;; ___ Diabetic nephropathy      ICD code: ______   Date of diagnosis: _________

 +13      ;; ___ Glomerulonephritis        ICD code: ______   Date of diagnosis: _________

 +14      ;; ___ Hydronephrosis            ICD code: ______   Date of diagnosis: _________

 +15      ;; ___ Interstitial nephritis    ICD code: ______   Date of diagnosis: _________

 +16      ;; ___ Kidney transplant         ICD code: ______   Date of diagnosis: _________

 +17      ;; ___ Nephrosclerosis           ICD code: ______   Date of diagnosis: _________

 +18      ;; ___ Nephrolithiasis           ICD code: ______   Date of diagnosis: _________

 +19      ;; ___ Renal artery stenosis     ICD code: ______   Date of diagnosis: _________

 +20      ;; ___ Ureterolithiasis          ICD code: ______   Date of diagnosis: _________

 +21      ;; ___ Neoplasm of the kidney    ICD code: ______   Date of diagnosis: _________

 +22      ;; ___ Cholesterol emboli        ICD code: ______   Date of diagnosis: _________

 +23      ;; ___ Cystic kidney disease     ICD code: ______   Date of diagnosis: _________

 +24      ;; ___ Congenital kidney disorder

 +25      ;;                               ICD code: ______   Date of diagnosis: _________

 +26      ;; ___ Other inherited kidney disorder, specify:

 +27      ;;                               ICD code: ______   Date of diagnosis: _________

 +28      ;; ___ Other kidney condition (specify diagnosis, providing only diagnoses

 +29      ;;     that pertain to kidney conditions.)

 +30      ;;

 +31      ;;     Other diagnosis #1: ______________

 +32      ;;     ICD code: ________________________

 +33      ;;     Date of diagnosis: _______________

 +34      ;;

 +35      ;;     Other diagnosis #2: ______________

 +36      ;;     ICD code: ________________________

 +37      ;;     Date of diagnosis: _______________

 +38      ;;

 +39      ;; If there are additional diagnoses that pertain to kidney conditions, list

 +40      ;; using above format: ________________________________________________________

 +41      ;;^TOF^

 +42      ;; 2. Medical history

 +43      ;;

 +44      ;; a. Describe the history (including cause, onset and course) of the Veteran's

 +45      ;; kidney condition (brief summary): __________________________________________

 +46      ;; b. Does the Veteran's treatment plan include taking continuous medication

 +47      ;; for the diagnosed condition?

 +48      ;; ___ Yes   ___ No

 +49      ;; List medications taken for the diagnosed condition:

 +50      ;; ____________________________________________________________________________

 +51      ;;

 +52      ;; 3. Renal dysfunction

 +53      ;;

 +54      ;; Does the Veteran have renal dysfunction? (Evidence of renal dysfunction

 +55      ;; includes either persistent proteinuria, hematuria or GFR < 60 cc/min/1.73m2)

 +56      ;; ___ Yes   ___ No

 +57      ;; If yes, complete the following section:

 +58      ;;

 +59      ;; a. Does the Veteran require regular dialysis?

 +60      ;; ___ Yes   ___ No

 +61      ;;

 +62      ;; b. Does the Veteran have any signs or symptoms due to renal dysfunction?

 +63      ;; ___ Yes   ___ No

 +64      ;;

 +65      ;; If yes,check all that apply:

 +66      ;;

 +67      ;;    ___ Proteinuria (albuminuria)

 +68      ;;        If checked, indicate frequency: (check all that apply)

 +69      ;;              ___ Recurring   ___ Constant   ___ Persistent

 +70      ;;    ___ Edema (due to renal dysfunction)

 +71      ;;        If checked, indicate frequency: (check all that apply)

 +72      ;;              ___ Some   ___ Transient   ___ Slight   ___ Persistent

 +73      ;;    ___ Anorexia (due to renal dysfunction)

 +74      ;;    ___ Weight loss (due to renal dysfunction)

 +75      ;;        If checked, provide baseline weight (average weight for 2-year period

 +76      ;;        preceding onset of disease): ____________

 +77      ;;        Provide current weight: _________________

 +78      ;;    ___ Generalized poor health due to renal dysfunction

 +79      ;;    ___ Lethargy due to renal dysfunction

 +80      ;;    ___ Weakness due to renal dysfunction

 +81      ;;    ___ Limitation of exertion due to renal dysfunction

 +82      ;;    ___ Able to perform only sedentary activity, due to persistent edema

 +83      ;;        caused by renal dysfunction

 +84      ;;    ___ Markedly decreased function of other organ systems, especially the

 +85      ;;        cardiovascular system, caused by renal dysfunction

 +86      ;;           If checked, describe: _____________________________________________

 +87      ;;    ___ Other, describe: _____________________________________________________

 +88      ;;^TOF^

 +89      ;; c. Does the Veteran have hypertension and/or heart disease due to renal

 +90      ;; dysfunction or caused by any kidney condition?

 +91      ;; ___ Yes   ___ No

 +92      ;;

 +93      ;; If yes, also complete the Hypertension and/or Heart Disease Questionnaire

 +94      ;; as appropriate.

 +95      ;;

 +96      ;; 4. Urolithiasis

 +97      ;;

 +98      ;; Does the Veteran now have or has he/she ever had kidney, ureteral or

 +99      ;; bladder calculi (urolithiasis)?

 +100     ;; ___ Yes   ___  No

 +101     ;; If yes, complete the following section:

 +102     ;;

 +103     ;; a. Indicate current/past location of calculi (check all that apply)

 +104     ;;    ___ Kidney   ___ Ureter   ___Bladder

 +105     ;;

 +106     ;; b. Has the Veteran had treatment for recurrent stone formation in the kidney,

 +107     ;; ureter or bladder?

 +108     ;; ___ Yes   ___  No

 +109     ;;

 +110     ;; If yes, indicate treatment: (check all that apply)

 +111     ;;   ___ Diet therapy

 +112     ;;       If checked, specify diet and dates of use: ____________________________

 +113     ;;   ___ Drug therapy

 +114     ;;       If checked, list medication and dates of use: _________________________

 +115     ;;   ___ Invasive or non-invasive procedures

 +116     ;;       If checked, indicate average number of times per year invasive or

 +117     ;;       non-invasive procedures were required:

 +118     ;;       ___ 0 to 1 per year    ___ 2 per year    ___ > 2 per year

 +119     ;;       Date and facility of most recent invasive or non-invasive procedure:

 +120     ;;       _______________________________________________________________________

 +121     ;;

 +122     ;; c. Does the Veteran have any signs or symptoms due to urolithiasis?

 +123     ;; ___ Yes   ___  No

 +124     ;;

 +125     ;; If yes, indicate severity (check all that apply):

 +126     ;;   ___ No symptoms or attacks of colic

 +127     ;;   ___ Occasional attacks of colic

 +128     ;;   ___ Frequent attacks of colic

 +129     ;;   ___ Causing voiding dysfunction

 +130     ;;   ___ Requires catheter drainage

 +131     ;;   ___ Causing infection (pyonephrosis)

 +132     ;;   ___ Causing hydronephrosis

 +133     ;;   ___ Causing impaired kidney function

 +134     ;;   ___ Other, describe: ______________________________________________________

 +135     ;;^TOF^

 +136     ;; 5. Urinary tract/kidney infection

 +137     ;;

 +138     ;; Does the Veteran have a history of recurrent symptomatic urinary tract or

 +139     ;; kidney infections?

 +140     ;; ___ Yes   ___  No

 +141     ;; If yes, complete the following section:

 +142     ;;

 +143     ;; a. Etiology of recurrent urinary tract or kidney infections:

 +144     ;; ____________________________________________________________________________

 +145     ;;

 +146     ;; b. Indicate all treatment modalities used for recurrent urinary tract or kidney

 +147     ;; infections (check all that apply):

 +148     ;;   ___ No treatment

 +149     ;;   ___ Long-term drug therapy

 +150     ;;       If checked, list medications used and indicate dates for courses of

 +151     ;;       treatment over the past 12 months: ___________________________________

 +152     ;;   ___ Hospitalization

 +153     ;;       If checked, indicate frequency of hospitalization:

 +154     ;;          ___ 1 or 2 per year

 +155     ;;          ___ > 2 per year

 +156     ;;   ___ Drainage

 +157     ;;         If checked, indicate dates when drainage performed over past 12

 +158     ;;         months: _______________________________

 +159     ;;   ___ Continuous intensive management

 +160     ;;         If checked, indicate types of treatment and medications used over

 +161     ;;         past 12 months: _______________________

 +162     ;;   ___ Intermittent intensive management

 +163     ;;         If checked, indicate types of treatment and medications used over

 +164     ;;         past 12 months: _______________________

 +165     ;;   ___ Other, describe: ________________________

 +166     ;;

 +167     ;; 6. Kidney transplant or removal

 +168     ;;

 +169     ;; Has the Veteran had a kidney transplant or removal?

 +170     ;; ___ Yes   ___ No

 +171     ;; If yes, complete the following section:

 +172     ;;

 +173     ;; a. Has the Veteran had a kidney removed?

 +174     ;; ___ Yes   ___ No

 +175     ;; If yes, provide reason:

 +176     ;;    ___ Kidney donation

 +177     ;;    ___ Due to disease

 +178     ;;    ___ Due to trauma or injury

 +179     ;;    ___ Other, describe: ______________________

 +180     ;;^TOF^

 +181     ;; b. Has the Veteran had a kidney transplant?

 +182     ;; ___ Yes   ___ No

 +183     ;;

 +184     ;; If yes, date of transplant: __________________

 +185     ;; Name of treatment facility, date of admission and date of discharge for

 +186     ;; transplant: ________________________________________________________________

 +187     ;;

 +188     ;; 7. Tumors and neoplasms

 +189     ;;

 +190     ;; a. Does the Veteran have a benign or malignant neoplasm or metastases

 +191     ;; related to any of the diagnoses in the Diagnosis section?

 +192     ;; ___ Yes   ___ No

 +193     ;;

 +194     ;; If yes, complete the following section:

 +195     ;;

 +196     ;; b. Is the neoplasm

 +197     ;; ___ Benign    ___ Malignant

 +198     ;;

 +199     ;; c. Has the Veteran completed treatment or is the Veteran currently undergoing

 +200     ;; treatment for a benign or malignant neoplasm or metastases?

 +201     ;; ___ Yes   ___ No; watchful waiting

 +202     ;;

 +203     ;;    If yes, indicate type of treatment the Veteran is currently undergoing or

 +204     ;;    has completed (check all that apply):

 +205     ;;    ___ Treatment completed; currently in watchful waiting status

 +206     ;;    ___ Surgery

 +207     ;;        If checked, describe: ________________________________________________

 +208     ;;        Date(s) of surgery: _________

 +209     ;;    ___ Radiation therapy

 +210     ;;        Date of most recent treatment: ___________

 +211     ;;        Date of completion of treatment or anticipated date of

 +212     ;;        completion: _________________

 +213     ;;    ___ Antineoplastic chemotherapy

 +214     ;;        Date of most recent treatment: ___________

 +215     ;;        Date of completion of treatment or anticipated date of

 +216     ;;        completion: _________________

 +217     ;;    ___ Other therapeutic procedure

 +218     ;;        If checked, describe procedure: ______________________________________

 +219     ;;        Date of most recent procedure: ___________

 +220     ;;    ___ Other therapeutic treatment

 +221     ;;        If checked, describe treatment: ______________________________________

 +222     ;;        Date of completion of treatment or anticipated date of

 +223     ;;        completion: _________________

 +224     ;;^TOF^

 +225     ;; d. Does the Veteran currently have any residual conditions or complications

 +226     ;; due to the neoplasm (including metastases) or its treatment, other than those

 +227     ;; already documented in the report above?

 +228     ;; ___ Yes   ___ No

 +229     ;;

 +230     ;; If yes, list residual conditions and complications (brief summary): _________

 +231     ;; _____________________________________________________________________________

 +232     ;;

 +233     ;; e. If there are additional benign or malignant neoplasms or metastases

 +234     ;; related to any of the diagnoses in the Diagnosis section, describe using the

 +235     ;; above format: _______________________________________________________________

 +236     ;;

 +237     ;; 8. Other pertinent physical findings, complications, conditions, signs and/or

 +238     ;; symptoms

 +239     ;;

 +240     ;; a. Does the Veteran have any scars (surgical or otherwise) related to any

 +241     ;; conditions or to the treatment of any conditions listed in the Diagnosis

 +242     ;; section above?

 +243     ;; ___ Yes   ___ No

 +244     ;;    If yes, are any of the scars painful and/or unstable, or is the total area

 +245     ;;    of all related scars greater than 39 square cm (6 square inches)?

 +246     ;;    ___ Yes   ___ No

 +247     ;;    If yes, also complete a Scars Questionnaire.

 +248     ;;

 +249     ;; b. Does the Veteran have any other pertinent physical findings,

 +250     ;; complications, conditions, signs or symptoms?

 +251     ;; ___ Yes   ___ No

 +252     ;;

 +253     ;; If yes, describe (brief summary): __________________________________________

 +254     ;;

 +255     ;; 9. Diagnostic testing

 +256     ;;

 +257     ;; NOTE: If laboratory test results are in the medical record and reflect the

 +258     ;; Veteran's current renal function, repeat testing is not required. Provide

 +259     ;; testing completed appropriate to Veteran's condition; testing indicated below

 +260     ;; is not indicated for every kidney condition.

 +261     ;;

 +262     ;; a. Has the Veteran had laboratory or other diagnostic studies performed?

 +263     ;; ___ Yes   ___ No

 +264     ;;

 +265     ;; If yes, provide most recent results, if available:

 +266     ;;

 +267     ;; b. Laboratory studies

 +268     ;;    ___ BUN:                        Date: ___________   Result: _____________

 +269     ;;    ___ Creatinine:                 Date: ___________   Result: _____________

 +270     ;;    ___ EGFR:                       Date: ___________   Result: _____________

 +271     ;;^TOF^

 +272     ;; c. Urinalysis:

 +273     ;;    ___ Hyaline casts:              Date: ___________   Result: _____________

 +274     ;;    ___ Granular casts:             Date: ___________   Result: _____________

 +275     ;;    ___ RBC's/HPF:                  Date: ___________   Result: _____________

 +276     ;;    ___ Proteinuria (albumin):      Date: ___________   Result: _____________

 +277     ;;    ___ Spot urine for

 +278     ;;        protein/creatinine ratio:   Date: ___________   Result: _____________

 +279     ;;    ___ 24 hour protein (mg/day):   Date: ___________   Result: _____________

 +280     ;;

 +281     ;; d. Spot urine microalbumin/creatinine:

 +282     ;;                                    Date: ___________   Result: _____________

 +283     ;;

 +284     ;; e. Are there any other significant diagnostic test findings and/or results?

 +285     ;; ___ Yes   ___ No

 +286     ;;

 +287     ;; If yes, provide type of test or procedure, date and results (brief summary):

 +288     ;; _____________________________________________________________________________

 +289     ;;

 +290      QUIT

DVBCQKC4.m