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Routine: DVBCQMO4

DVBCQMO4.m

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  1. DVBCQMO4 ;;ALB-CIOFO/ECF,SBW - MEDICAL OPINION QUESTIONNAIRE ; 14/JUNE/2011
  1. ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
  1. ;
  1. TXT ;
  1. ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1. ;; disability benefits. VA will consider the information you provide on this
  1. ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1. ;;
  1. ;; 1. Definitions
  1. ;;
  1. ;; Aggravation of preexisting nonservice-connected disabilities.
  1. ;; A preexisting injury or disease will be considered to have been aggravated
  1. ;; by active military, naval, or air service, where there is an increase in
  1. ;; disability during such service, unless there is a specific finding that the
  1. ;; increase in disability is due to the natural progress of the disease.
  1. ;;
  1. ;; Aggravation of nonservice-connected disabilities.
  1. ;; Any increase in severity of a nonservice-connected disease or injury that
  1. ;; is proximately due to or the result of a service-connected disease or injury,
  1. ;; and not due to the natural progress of the nonservice-connected disease, will
  1. ;; be service connected.
  1. ;;
  1. ;; 2. Restatement of requested opinion
  1. ;;
  1. ;; a. Insert requested opinion from general remarks: __________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; b. Indicate type of exam for which opinion has been requested (e.g. Skin
  1. ;; Diseases): _________________________________________________________________
  1. ;;
  1. ;; 3. Evidence review
  1. ;;
  1. ;; Was the Veteran's VA claims file reviewed?
  1. ;; ___ Yes ___ No
  1. ;; If yes, list any records that were reviewed but were not included in the
  1. ;; Veteran's VA claims file: __________________________________________________
  1. ;; If no, check all records reviewed:
  1. ;; ___ Military service treatment records
  1. ;; ___ Military service personnel records
  1. ;; ___ Military enlistment examination
  1. ;; ___ Military separation examination
  1. ;; ___ Military post-deployment questionnaire
  1. ;; ___ Department of Defense Form 214 Separation Documents
  1. ;; ___ Veterans Health Administration medical records (VA treatment records)
  1. ;; ___ Civilian medical records
  1. ;; ___ Interviews with collateral witnesses (family and others who have
  1. ;; known the veteran before and after military service)
  1. ;; ___ No records were reviewed
  1. ;; ___ Other: ______________________________________
  1. ;;
  1. ;; Complete only the sections below that you are asked to complete in the
  1. ;; Medical Opinion DBQ request.
  1. ;;^TOF^
  1. ;; 4. Medical opinion for direct service connection
  1. ;;
  1. ;; Choose the statement that most closely approximates the etiology of the
  1. ;; claimed condition.
  1. ;;
  1. ;; a. ___ The claimed condition was at least as likely as not (50 percent or
  1. ;; greater probability) incurred in or caused by the claimed in-service injury,
  1. ;; event, or illness. Provide rationale in section c.
  1. ;;
  1. ;; b. ___ The claimed condition was less likely than not (less than 50 percent
  1. ;; probability) incurred in or caused by the claimed in-service injury, event,
  1. ;; or illness. Provide rationale in section c.
  1. ;;
  1. ;; c. Rationale: ______________________________________________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; 5. Medical opinion for secondary service connection
  1. ;;
  1. ;; a. ___ The claimed condition is at least as likely as not (50 percent or
  1. ;; greater probability) proximately due to or the result of the Veteran's
  1. ;; service connected condition. Provide rationale in section c.
  1. ;;
  1. ;; b. ___ The claimed condition is less likely than not (less than 50 percent
  1. ;; probability) proximately due to or the result of the Veteran's service
  1. ;; connected condition. Provide rationale in section c.
  1. ;;
  1. ;; c. Rationale: ______________________________________________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; 6. Medical opinion for aggravation of a condition that existed prior to
  1. ;; service
  1. ;;
  1. ;; a. ___ The claimed condition, which clearly and unmistakably existed prior
  1. ;; to service, was aggravated beyond its natural progression by an in-service
  1. ;; injury, event, or illness. Provide rationale in section c.
  1. ;;
  1. ;; b. ___ The claimed condition, which clearly and unmistakably existed prior
  1. ;; to service, was clearly and unmistakably not aggravated beyond its natural
  1. ;; progression by an in-service injury, event, or illness. Provide rationale
  1. ;; in section c.
  1. ;;
  1. ;; c. Rationale: ______________________________________________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;^TOF^
  1. ;; 7. Medical opinion for aggravation of a nonservice connected condition by a
  1. ;; service connected condition
  1. ;;
  1. ;; a. Can you determine a baseline level of severity of (claimed condition/
  1. ;; diagnosis) based upon medical evidence available prior to aggravation or the
  1. ;; earliest medical evidence following aggravation by (service connected
  1. ;; condition)?
  1. ;; ___ Yes ___ No
  1. ;; If "Yes" to question 7a., answer the following:
  1. ;; i. Describe the baseline level of severity of (claimed condition/
  1. ;; diagnosis) based upon medical evidence available prior to aggravation
  1. ;; or the earliest medical evidence following aggravation by (service
  1. ;; connected condition):
  1. ;; _______________________________________________________________________
  1. ;;
  1. ;; ii. Provide the date and nature of the medical evidence used to provide
  1. ;; the baseline: _________________________________________________________
  1. ;;
  1. ;; iii. Is the current severity of the (claimed condition/diagnosis) greater
  1. ;; than the baseline?
  1. ;; ___ Yes ___ No
  1. ;; If yes, was the Veteran's (claimed condition/diagnosis) at least as
  1. ;; likely as not aggravated beyond its natural progression by (insert
  1. ;; "service connected condition")?
  1. ;;
  1. ;; ___ Yes (provide rationale in section b.)
  1. ;; ___ No (provide rationale in section b.)
  1. ;;
  1. ;; If "No" to question 7a., answer the following:
  1. ;; i. Provide rationale as to why a baseline cannot be established (e.g.
  1. ;; medical evidence is not sufficient to support a determination of a
  1. ;; baseline level of severity): __________________________________________
  1. ;; ii. Regardless of an established baseline, was the Veteran's (claimed
  1. ;; condition/diagnosis) at least as likely as not aggravated beyond its
  1. ;; natural progression by (insert "service connected condition")?
  1. ;; ___ Yes (provide rationale in section b.)
  1. ;; ___ No (provide rationale in section b.)
  1. ;;
  1. ;; b. Provide rationale: ______________________________________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;;^TOF^
  1. ;; 8. Opinion regarding conflicting medical evidence
  1. ;;
  1. ;; I have reviewed the conflicting medical evidence and am providing the
  1. ;; following opinion:
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; Physician signature: ____________________________________ Date: ____________
  1. ;;
  1. ;; Physician printed name: _________________________________ Phone: ___________
  1. ;;
  1. ;; Medical license #: ______________________________________ Fax: _____________
  1. ;;
  1. ;; Physician address: _________________________________________________________
  1. ;;
  1. ;; NOTE: VA may request additional medical information, including additional
  1. ;; examinations if necessary to complete VA's review of the Veteran's
  1. ;; application.
  1. ;;^END^
  1. Q