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 Dec 13, 2024@01:47:02 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
