DVBCQLI2.m

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 ---DVBCQLI2   14848     printed  Apr 23, 2025@18:01:35                                                                                                                                                                                                   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