- DVBCQKC5 ;;ALB-CIOFO/ECF - KIDNEY CONDITIONS QUESTIONNAIRE CONTINUED (V2); 6/15/2011
- ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
- ;
- TXT ;
- ;; 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[HDVBCQKC5 1090 printed Jan 18, 2025@02:48:15 Page 2
- DVBCQKC5 ;;ALB-CIOFO/ECF - KIDNEY CONDITIONS QUESTIONNAIRE CONTINUED (V2); 6/15/2011
- +1 ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
- +2 ;
- TXT ;
- +1 ;; 10. Functional impact
- +2 ;;
- +3 ;; Does the Veteran's kidney condition(s), including neoplasms, if any, impact
- +4 ;; his or her ability to work?
- +5 ;; ___ Yes ___ No
- +6 ;;
- +7 ;; If yes, describe impact of each of the Veteran's kidney conditions,
- +8 ;; providing one or more examples: ____________________________________________
- +9 ;;
- +10 ;; 11. Remarks, if any: _______________________________________________________
- +11 ;;
- +12 ;; Physician signature: _____________________________________ Date: ___________
- +13 ;;
- +14 ;; Physician printed name: __________________________________ Phone: __________
- +15 ;;
- +16 ;; Medical license #: _______________________________________ Fax: ____________
- +17 ;;
- +18 ;; Physician address: _________________________________________________________
- +19 ;;
- +20 ;; NOTE: VA may request additional medical information, including additional
- +21 ;; examinations if necessary to complete VA's review of the Veteran's
- +22 ;; application.
- +23 ;;^END^
- +24 QUIT