DVBCQLI2 ;;ALB-CIOFO/SBW - LIVER QUESTIONNAIRE ; 27/JUNE/2011
;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
;
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 liver
;; condition?
;; ___ Yes ___ No
;;
;; If yes, select the Veteran's condition (check all that apply):
;; ___ Hepatitis A
;; ICD code: ______ Date of diagnosis: ____________ (complete Section I)
;; ___ Hepatitis B
;; ICD code: ______ Date of diagnosis: ____________ (complete Section I)
;; ___ Hepatitis C
;; ICD code: ______ Date of diagnosis: ____________ (complete Section I)
;; ___ Autoimmune hepatitis
;; ICD code: ______ Date of diagnosis: ____________ (complete Section I)
;; ___ Drug-induced hepatitis
;; ICD code: ______ Date of diagnosis: ____________ (complete Section I)
;; ___ Hemochromatosis
;; ICD code: ______ Date of diagnosis: ____________ (complete Section I)
;; ___ Cirrhosis of the liver
;; ICD code: ______ Date of diagnosis: ____________ (complete Section II)
;; ___ Primary biliary cirrhosis
;; ICD code: ______ Date of diagnosis: ____________ (complete Section II)
;; ___ Sclerosing cholangitis
;; ICD code: ______ Date of diagnosis: ____________ (complete Section II)
;; ___ Liver transplant candidate
;; ICD code: ______ Date of diagnosis: ____________ (complete Section III)
;; ___ Liver transplant
;; ICD code: ______ Date of diagnosis: ____________ (complete Section III)
;; ___ Other liver 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 liver conditions, list
;; using above format: _________________________________________________________
;;
;; NOTE: Determination of these conditions requires documentation by appropriate
;; serologic testing, abnormal liver function tests, and/or abnormal liver
;; biopsy or imaging tests. If test results are documented in the medical
;; record, additional testing is not required.
;;^TOF^
;; 2. Medical History
;; a. Describe the history (including cause, onset and course) of the Veteran's
;; liver conditions (brief summary): ___________________________________________
;;
;; b. Is continuous medication required for control of the Veteran's liver
;; conditions?
;; ___ Yes ___ No
;; If yes, list only those medications required for the liver conditions:
;; _____________________________________________________________________________
;;
;; SECTION I: Hepatitis (including hepatitis A, B and C, autoimmune or drug-
;; induced hepatitis, any other infectious liver disease and chronic liver
;; disease without cirrhosis)
;; a. Does the Veteran currently have signs or symptoms attributable to chronic
;; or infectious liver diseases?
;; ___ Yes ___ No
;; If yes, indicate signs and symptoms attributable to chronic or infectious
;; liver diseases (check all that apply):
;; ___ Fatigue
;; If checked, indicate frequency and severity:
;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
;; ___ Malaise
;; If checked, indicate frequency and severity:
;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
;; ___ Anorexia
;; If checked, indicate frequency and severity:
;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
;; ___ Nausea
;; If checked, indicate frequency and severity:
;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
;; ___ Vomiting
;; If checked, indicate frequency and severity:
;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
;; ___ Arthralgia
;; If checked, indicate frequency and severity:
;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
;; ___ Weight loss
;; If checked, provide baseline weight: _______ and current weight: _______
;; (For VA purposes, baseline weight is the average weight for 2-year
;; period preceding onset of disease)
;; Also, indicate if this weight loss has been sustained for three months
;; or longer: ___ Yes ___ No
;; ___ Right upper quadrant pain
;; If checked, indicate frequency and severity:
;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
;; ___ Hepatomegaly
;; ___ Condition requires dietary restriction
;; If checked, describe dietary restrictions: ____________________________
;; ___ Condition results in other indications of malnutrition
;; If checked, describe other indications of malnutrition: _______________
;; ___ Other, describe: _____________________________________________________
;;^TOF^
;; c. Has the Veteran been diagnosed with hepatitis C?
;; ___ Yes ___ No
;; If yes, indicate risk factors (check all that apply):
;; ___ Unknown
;; ___ No known risk factors
;; ___ Organ transplant before 1992
;; ___ Transfusions of blood or blood products before 1992
;; ___ Hemodialysis
;; ___ Accidental exposure to blood by health care workers (to include
;; combat medic or corpsman)
;; ___ Intravenous drug use or intranasal cocaine use
;; ___ High risk sexual activity
;; ___ Other direct percutaneous exposure to blood (such as by tattooing,
;; body piercing, acupuncture with non-sterile needles, shared
;; toothbrushes and/or shaving razors)
;; If checked, describe: ____________________________________________
;; ___ Other, describe: _____________________________________________________
;;
;; d. Has the Veteran had any incapacitating episodes (with symptoms such as
;; fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper
;; quadrant pain) due to the liver conditions during the past 12 months?
;; ___ Yes ___ No
;; If yes, provide the total duration of the incapacitating episodes over the
;; past 12 months:
;; ___ Less than 1 week
;; ___ At least 1 week but less than 2 weeks
;; ___ At least 2 weeks but less than 4 weeks
;; ___ At least 4 weeks but less than 6 weeks
;; ___ 6 weeks or more
;;
;; NOTE: For VA purposes, an incapacitating episode means a period of acute
;; symptoms severe enough to require bed rest and treatment by a physician.
;;^TOF^
;; SECTION II: Cirrhosis of the liver, biliary cirrhosis and cirrhotic phase of
;; sclerosing cholangitis
;; Does the Veteran currently have signs or symptoms attributable to cirrhosis
;; of the liver, biliary cirrhosis or cirrhotic phase of sclerosing cholangitis?
;; ___ Yes ___ No
;; If yes, indicate signs and symptoms attributable to cirrhosis of the liver,
;; biliary cirrhosis or cirrhotic phase of sclerosing cholangitis (check all
;; that apply):
;; ___ Weakness
;; If checked, indicate frequency and severity:
;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
;; ___ Anorexia
;; If checked, indicate frequency and severity:
;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
;; ___ Abdominal pain
;; If checked, indicate frequency and severity:
;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
;; ___ Malaise
;; If checked, indicate frequency and severity:
;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
;; ___ Weight loss
;; If checked, provide baseline weight: _______ and current weight: _______
;; (For VA purposes, baseline weight is the average weight for 2-year
;; period preceding onset of disease)
;; Also, indicate if this weight loss has been sustained for three months
;; or longer: ___ Yes ___ No
;; ___ Ascites
;; If checked, indicate frequency and severity: (check all that apply)
;; ___ 1 episode ___ 2 or more episodes
;; ___ Periods of remission between attacks ___ Refractory to treatment
;; Date of last episode of ascites: _______________
;; ___ Hepatic encephalopathy
;; If checked, indicate frequency and severity: (check all that apply)
;; ___ 1 episode ___ 2 or more episodes
;; ___ Periods of remission between attacks ___ Refractory to treatment
;; Date of last episode of hepatic encephalopathy: _______________
;; ___ Hemorrhage from varices or portal gastropathy (erosive gastritis)
;; If checked, indicate frequency and severity: (check all that apply)
;; ___ 1 episode ___ 2 or more episodes
;; ___ Periods of remission between attacks ___ Refractory to treatment
;; Date of last episode of hemorrhage from varices or portal gastropathy:
;; _______________
;; ___ Portal hypertension
;; ___ Splenomegaly
;; ___ Persistent jaundice
;;^TOF^
;; SECTION III: Liver transplant and/or liver injury
;; a. Is the Veteran a liver transplant candidate?
;; ___ Yes ___ No
;;
;; b. Is the Veteran currently hospitalized awaiting transplant?
;; ___ Yes ___ No
;; Date of hospital admission for this condition: ______________
;;
;; c. Has the Veteran undergone a liver transplant?
;; ___ Yes ___ No
;; Date(s) of surgery: __________________________________
;; Date of hospital discharge: __________________________________
;; Current signs and symptoms ___________________________
;;
;; d. Has the Veteran had an injury to the liver?
;; ___ Yes ___ No
;; If yes, does the Veteran have peritoneal adhesions resulting from an injury
;; to the liver?
;; ___ Yes ___ No
;; If yes, ALSO complete the Peritoneal Adhesions Questionnaire.
;;
;; 3. 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 and/or symptoms related to any conditions
;; listed in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): ___________________________________________
;;^TOF^
;; 4. Diagnostic testing
;; NOTE: Diagnosis of hepatitis C must be confirmed by recombinant immunoblot
;; assay (RIBA). If this information is of record, repeat RIBA test is not
;; required.
;; If testing has been performed and reflects Veteran's current condition, no
;; further testing is required for this examination report.
;;
;; a. Have imaging studies been performed and are the results available?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ EUS (Endoscopic ultrasound)
;; Date: ___________ Results: ______________
;; ___ ERCP (Endoscopic retrograde cholangiopancreatography)
;; Date: ___________ Results: ______________
;; ___ Transhepatic cholangiogram
;; Date: ___________ Results: ______________
;; ___ MRI or MRCP (magnetic resonance cholangiopancreatography)
;; Date: ___________ Results: ______________
;; ___ CT Date: ___________ Results: ______________
;; ___ Other, describe: __________________________
;; Date: ___________ Results: ______________
;;
;; b. Have laboratory studies been performed?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Recombinant immunoblot assay (RIBA)
;; Date: ___________ Results: ______________
;; ___ Hepatitis C genotype Date: ___________ Results: ______________
;; ___ Hepatitis C viral titers
;; Date: ___________ Results: ______________
;; ___ AST Date: ___________ Results: ______________
;; ___ ALT Date: ___________ Results: ______________
;; ___ Alkaline phosphatase Date: ___________ Results: ______________
;; ___ Bilirubin Date: ___________ Results: ______________
;; ___ INR (PT) Date: ___________ Results: ______________
;; ___ Creatinine Date: ___________ Results: ______________
;; ___ MELD score Date: ___________ Results: ______________
;; ___ Other, describe: Date: ___________ Results: ______________
;;
;; c. Has a liver biopsy been performed?
;; ___ Yes ___ No Date of test: ___________ Results: ______________
;;
;; d. 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):
;; _____________________________________________________________________________
;;^TOF^
;; 5. Functional impact
;; Does the Veteran's liver condition impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's liver conditions,
;; providing one or more examples: _____________________________________________
;;
;; 6. Remarks, if any: _________________________________________________________
;;
;; Physician signature: _____________________________________ Date: ____________
;;
;; Physician printed name: _______________________________________
;;
;; Medical license #: _____________ Physician address: _________________________
;;
;; Phone: ____________________________ Fax: ____________________________
;;
;; 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[HDVBCQLI2 14848 printed Nov 22, 2024@16:57:18 Page 2
DVBCQLI2 ;;ALB-CIOFO/SBW - LIVER QUESTIONNAIRE ; 27/JUNE/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+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 ;; Does the Veteran now have or has he/she ever been diagnosed with a liver
+7 ;; condition?
+8 ;; ___ Yes ___ No
+9 ;;
+10 ;; If yes, select the Veteran's condition (check all that apply):
+11 ;; ___ Hepatitis A
+12 ;; ICD code: ______ Date of diagnosis: ____________ (complete Section I)
+13 ;; ___ Hepatitis B
+14 ;; ICD code: ______ Date of diagnosis: ____________ (complete Section I)
+15 ;; ___ Hepatitis C
+16 ;; ICD code: ______ Date of diagnosis: ____________ (complete Section I)
+17 ;; ___ Autoimmune hepatitis
+18 ;; ICD code: ______ Date of diagnosis: ____________ (complete Section I)
+19 ;; ___ Drug-induced hepatitis
+20 ;; ICD code: ______ Date of diagnosis: ____________ (complete Section I)
+21 ;; ___ Hemochromatosis
+22 ;; ICD code: ______ Date of diagnosis: ____________ (complete Section I)
+23 ;; ___ Cirrhosis of the liver
+24 ;; ICD code: ______ Date of diagnosis: ____________ (complete Section II)
+25 ;; ___ Primary biliary cirrhosis
+26 ;; ICD code: ______ Date of diagnosis: ____________ (complete Section II)
+27 ;; ___ Sclerosing cholangitis
+28 ;; ICD code: ______ Date of diagnosis: ____________ (complete Section II)
+29 ;; ___ Liver transplant candidate
+30 ;; ICD code: ______ Date of diagnosis: ____________ (complete Section III)
+31 ;; ___ Liver transplant
+32 ;; ICD code: ______ Date of diagnosis: ____________ (complete Section III)
+33 ;; ___ Other liver conditions:
+34 ;;
+35 ;; Other diagnosis #1: ______________
+36 ;; ICD code: _____________________
+37 ;; Date of diagnosis: _______________
+38 ;;
+39 ;; Other diagnosis #2: ______________
+40 ;; ICD code: _____________________
+41 ;; Date of diagnosis: _______________
+42 ;;
+43 ;; If there are additional diagnoses that pertain to liver conditions, list
+44 ;; using above format: _________________________________________________________
+45 ;;
+46 ;; NOTE: Determination of these conditions requires documentation by appropriate
+47 ;; serologic testing, abnormal liver function tests, and/or abnormal liver
+48 ;; biopsy or imaging tests. If test results are documented in the medical
+49 ;; record, additional testing is not required.
+50 ;;^TOF^
+51 ;; 2. Medical History
+52 ;; a. Describe the history (including cause, onset and course) of the Veteran's
+53 ;; liver conditions (brief summary): ___________________________________________
+54 ;;
+55 ;; b. Is continuous medication required for control of the Veteran's liver
+56 ;; conditions?
+57 ;; ___ Yes ___ No
+58 ;; If yes, list only those medications required for the liver conditions:
+59 ;; _____________________________________________________________________________
+60 ;;
+61 ;; SECTION I: Hepatitis (including hepatitis A, B and C, autoimmune or drug-
+62 ;; induced hepatitis, any other infectious liver disease and chronic liver
+63 ;; disease without cirrhosis)
+64 ;; a. Does the Veteran currently have signs or symptoms attributable to chronic
+65 ;; or infectious liver diseases?
+66 ;; ___ Yes ___ No
+67 ;; If yes, indicate signs and symptoms attributable to chronic or infectious
+68 ;; liver diseases (check all that apply):
+69 ;; ___ Fatigue
+70 ;; If checked, indicate frequency and severity:
+71 ;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
+72 ;; ___ Malaise
+73 ;; If checked, indicate frequency and severity:
+74 ;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
+75 ;; ___ Anorexia
+76 ;; If checked, indicate frequency and severity:
+77 ;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
+78 ;; ___ Nausea
+79 ;; If checked, indicate frequency and severity:
+80 ;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
+81 ;; ___ Vomiting
+82 ;; If checked, indicate frequency and severity:
+83 ;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
+84 ;; ___ Arthralgia
+85 ;; If checked, indicate frequency and severity:
+86 ;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
+87 ;; ___ Weight loss
+88 ;; If checked, provide baseline weight: _______ and current weight: _______
+89 ;; (For VA purposes, baseline weight is the average weight for 2-year
+90 ;; period preceding onset of disease)
+91 ;; Also, indicate if this weight loss has been sustained for three months
+92 ;; or longer: ___ Yes ___ No
+93 ;; ___ Right upper quadrant pain
+94 ;; If checked, indicate frequency and severity:
+95 ;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
+96 ;; ___ Hepatomegaly
+97 ;; ___ Condition requires dietary restriction
+98 ;; If checked, describe dietary restrictions: ____________________________
+99 ;; ___ Condition results in other indications of malnutrition
+100 ;; If checked, describe other indications of malnutrition: _______________
+101 ;; ___ Other, describe: _____________________________________________________
+102 ;;^TOF^
+103 ;; c. Has the Veteran been diagnosed with hepatitis C?
+104 ;; ___ Yes ___ No
+105 ;; If yes, indicate risk factors (check all that apply):
+106 ;; ___ Unknown
+107 ;; ___ No known risk factors
+108 ;; ___ Organ transplant before 1992
+109 ;; ___ Transfusions of blood or blood products before 1992
+110 ;; ___ Hemodialysis
+111 ;; ___ Accidental exposure to blood by health care workers (to include
+112 ;; combat medic or corpsman)
+113 ;; ___ Intravenous drug use or intranasal cocaine use
+114 ;; ___ High risk sexual activity
+115 ;; ___ Other direct percutaneous exposure to blood (such as by tattooing,
+116 ;; body piercing, acupuncture with non-sterile needles, shared
+117 ;; toothbrushes and/or shaving razors)
+118 ;; If checked, describe: ____________________________________________
+119 ;; ___ Other, describe: _____________________________________________________
+120 ;;
+121 ;; d. Has the Veteran had any incapacitating episodes (with symptoms such as
+122 ;; fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper
+123 ;; quadrant pain) due to the liver conditions during the past 12 months?
+124 ;; ___ Yes ___ No
+125 ;; If yes, provide the total duration of the incapacitating episodes over the
+126 ;; past 12 months:
+127 ;; ___ Less than 1 week
+128 ;; ___ At least 1 week but less than 2 weeks
+129 ;; ___ At least 2 weeks but less than 4 weeks
+130 ;; ___ At least 4 weeks but less than 6 weeks
+131 ;; ___ 6 weeks or more
+132 ;;
+133 ;; NOTE: For VA purposes, an incapacitating episode means a period of acute
+134 ;; symptoms severe enough to require bed rest and treatment by a physician.
+135 ;;^TOF^
+136 ;; SECTION II: Cirrhosis of the liver, biliary cirrhosis and cirrhotic phase of
+137 ;; sclerosing cholangitis
+138 ;; Does the Veteran currently have signs or symptoms attributable to cirrhosis
+139 ;; of the liver, biliary cirrhosis or cirrhotic phase of sclerosing cholangitis?
+140 ;; ___ Yes ___ No
+141 ;; If yes, indicate signs and symptoms attributable to cirrhosis of the liver,
+142 ;; biliary cirrhosis or cirrhotic phase of sclerosing cholangitis (check all
+143 ;; that apply):
+144 ;; ___ Weakness
+145 ;; If checked, indicate frequency and severity:
+146 ;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
+147 ;; ___ Anorexia
+148 ;; If checked, indicate frequency and severity:
+149 ;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
+150 ;; ___ Abdominal pain
+151 ;; If checked, indicate frequency and severity:
+152 ;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
+153 ;; ___ Malaise
+154 ;; If checked, indicate frequency and severity:
+155 ;; ___ Intermittent ___ Daily ___ Near-constant and debilitating
+156 ;; ___ Weight loss
+157 ;; If checked, provide baseline weight: _______ and current weight: _______
+158 ;; (For VA purposes, baseline weight is the average weight for 2-year
+159 ;; period preceding onset of disease)
+160 ;; Also, indicate if this weight loss has been sustained for three months
+161 ;; or longer: ___ Yes ___ No
+162 ;; ___ Ascites
+163 ;; If checked, indicate frequency and severity: (check all that apply)
+164 ;; ___ 1 episode ___ 2 or more episodes
+165 ;; ___ Periods of remission between attacks ___ Refractory to treatment
+166 ;; Date of last episode of ascites: _______________
+167 ;; ___ Hepatic encephalopathy
+168 ;; If checked, indicate frequency and severity: (check all that apply)
+169 ;; ___ 1 episode ___ 2 or more episodes
+170 ;; ___ Periods of remission between attacks ___ Refractory to treatment
+171 ;; Date of last episode of hepatic encephalopathy: _______________
+172 ;; ___ Hemorrhage from varices or portal gastropathy (erosive gastritis)
+173 ;; If checked, indicate frequency and severity: (check all that apply)
+174 ;; ___ 1 episode ___ 2 or more episodes
+175 ;; ___ Periods of remission between attacks ___ Refractory to treatment
+176 ;; Date of last episode of hemorrhage from varices or portal gastropathy:
+177 ;; _______________
+178 ;; ___ Portal hypertension
+179 ;; ___ Splenomegaly
+180 ;; ___ Persistent jaundice
+181 ;;^TOF^
+182 ;; SECTION III: Liver transplant and/or liver injury
+183 ;; a. Is the Veteran a liver transplant candidate?
+184 ;; ___ Yes ___ No
+185 ;;
+186 ;; b. Is the Veteran currently hospitalized awaiting transplant?
+187 ;; ___ Yes ___ No
+188 ;; Date of hospital admission for this condition: ______________
+189 ;;
+190 ;; c. Has the Veteran undergone a liver transplant?
+191 ;; ___ Yes ___ No
+192 ;; Date(s) of surgery: __________________________________
+193 ;; Date of hospital discharge: __________________________________
+194 ;; Current signs and symptoms ___________________________
+195 ;;
+196 ;; d. Has the Veteran had an injury to the liver?
+197 ;; ___ Yes ___ No
+198 ;; If yes, does the Veteran have peritoneal adhesions resulting from an injury
+199 ;; to the liver?
+200 ;; ___ Yes ___ No
+201 ;; If yes, ALSO complete the Peritoneal Adhesions Questionnaire.
+202 ;;
+203 ;; 3. Other pertinent physical findings, complications, conditions, signs
+204 ;; and/or symptoms
+205 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+206 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+207 ;; section above?
+208 ;; ___ Yes ___ No
+209 ;; If yes, are any of the scars painful and/or unstable, or is the total area of
+210 ;; all related scars greater than 39 square cm (6 square inches)?
+211 ;; ___ Yes ___ No
+212 ;; If yes, also complete a Scars Questionnaire.
+213 ;;
+214 ;; b. Does the Veteran have any other pertinent physical findings,
+215 ;; complications, conditions, signs and/or symptoms related to any conditions
+216 ;; listed in the Diagnosis section above?
+217 ;; ___ Yes ___ No
+218 ;; If yes, describe (brief summary): ___________________________________________
+219 ;;^TOF^
+220 ;; 4. Diagnostic testing
+221 ;; NOTE: Diagnosis of hepatitis C must be confirmed by recombinant immunoblot
+222 ;; assay (RIBA). If this information is of record, repeat RIBA test is not
+223 ;; required.
+224 ;; If testing has been performed and reflects Veteran's current condition, no
+225 ;; further testing is required for this examination report.
+226 ;;
+227 ;; a. Have imaging studies been performed and are the results available?
+228 ;; ___ Yes ___ No
+229 ;; If yes, check all that apply:
+230 ;; ___ EUS (Endoscopic ultrasound)
+231 ;; Date: ___________ Results: ______________
+232 ;; ___ ERCP (Endoscopic retrograde cholangiopancreatography)
+233 ;; Date: ___________ Results: ______________
+234 ;; ___ Transhepatic cholangiogram
+235 ;; Date: ___________ Results: ______________
+236 ;; ___ MRI or MRCP (magnetic resonance cholangiopancreatography)
+237 ;; Date: ___________ Results: ______________
+238 ;; ___ CT Date: ___________ Results: ______________
+239 ;; ___ Other, describe: __________________________
+240 ;; Date: ___________ Results: ______________
+241 ;;
+242 ;; b. Have laboratory studies been performed?
+243 ;; ___ Yes ___ No
+244 ;; If yes, check all that apply:
+245 ;; ___ Recombinant immunoblot assay (RIBA)
+246 ;; Date: ___________ Results: ______________
+247 ;; ___ Hepatitis C genotype Date: ___________ Results: ______________
+248 ;; ___ Hepatitis C viral titers
+249 ;; Date: ___________ Results: ______________
+250 ;; ___ AST Date: ___________ Results: ______________
+251 ;; ___ ALT Date: ___________ Results: ______________
+252 ;; ___ Alkaline phosphatase Date: ___________ Results: ______________
+253 ;; ___ Bilirubin Date: ___________ Results: ______________
+254 ;; ___ INR (PT) Date: ___________ Results: ______________
+255 ;; ___ Creatinine Date: ___________ Results: ______________
+256 ;; ___ MELD score Date: ___________ Results: ______________
+257 ;; ___ Other, describe: Date: ___________ Results: ______________
+258 ;;
+259 ;; c. Has a liver biopsy been performed?
+260 ;; ___ Yes ___ No Date of test: ___________ Results: ______________
+261 ;;
+262 ;; d. Are there any other significant diagnostic test findings and/or results?
+263 ;; ___ Yes ___ No
+264 ;; If yes, provide type of test or procedure, date and results (brief summary):
+265 ;; _____________________________________________________________________________
+266 ;;^TOF^
+267 ;; 5. Functional impact
+268 ;; Does the Veteran's liver condition impact his or her ability to work?
+269 ;; ___ Yes ___ No
+270 ;; If yes, describe the impact of each of the Veteran's liver conditions,
+271 ;; providing one or more examples: _____________________________________________
+272 ;;
+273 ;; 6. Remarks, if any: _________________________________________________________
+274 ;;
+275 ;; Physician signature: _____________________________________ Date: ____________
+276 ;;
+277 ;; Physician printed name: _______________________________________
+278 ;;
+279 ;; Medical license #: _____________ Physician address: _________________________
+280 ;;
+281 ;; Phone: ____________________________ Fax: ____________________________
+282 ;;
+283 ;; NOTE: VA may request additional medical information, including additional
+284 ;; examinations if necessary to complete VA's review of the Veteran's application.
+285 ;;^END^
+286 QUIT
