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Routine: DVBCQKC5

DVBCQKC5.m

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  1. DVBCQKC5 ;;ALB-CIOFO/ECF - KIDNEY CONDITIONS QUESTIONNAIRE CONTINUED (V2); 6/15/2011
  1. ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
  1. ;
  1. TXT ;
  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,
  1. ;; providing 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