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):
;; _____________________________________________________________________________
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQKC4 13607 printed Apr 09, 2024@20:47:03 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
