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Routine: DVBCQKC5

DVBCQKC5.m

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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^

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