DVBCQMR2.m

DVBCQMR2 ;;ALB-CIOFO/ECF - MALE REPRODUCTIVE SYSTEM CONDITIONS QUESTIONNAIRE ; 2/15/2011

 ;;2.7;AMIE;**163**;Apr 10, 1995;Build 5

 ;

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 ever been diagnosed with any conditions

 ;; of the male reproductive system?

 ;; ___ Yes   ___ No

 ;;

 ;; If no, provide rationale (e.g., Veteran has never had  any known male

 ;; reproductive organ conditions): _____________________________________________

 ;;

 ;; If yes, indicate diagnoses: (check all that apply)

 ;; ___ Erectile dysfunction    ICD Code: ______  Date of Diagnosis: ____________

 ;; ___ Penis, deformity (e.g., Peyronie's)

 ;;                             ICD Code: ______  Date of Diagnosis: ____________

 ;; ___ Testis, atrophy, one or both

 ;;                             ICD Code: ______  Date of Diagnosis: ____________

 ;; ___ Testis, removal, one or both

 ;;                             ICD Code: ______  Date of Diagnosis: ____________

 ;; ___ Epididymitis, chronic   ICD Code: ______  Date of Diagnosis: ____________

 ;; ___ Epididymo-orchitis,  chronic

 ;;                             ICD Code: ______  Date of Diagnosis: ____________

 ;; ___ Prostate injury         ICD Code: ______  Date of Diagnosis: ____________

 ;; ___ Prostate hypertrophy (BPH)

 ;;                             ICD Code: ______  Date of Diagnosis: ____________

 ;; ___ Prostatitis, chronic    ICD Code: ______  Date of Diagnosis: ____________

 ;; ___ Prostate surgical residuals (as addressed in items 3-6)

 ;;                             ICD Code: ______  Date of Diagnosis: ____________

 ;; ___ Neoplasms of the male reproductive system

 ;;                             ICD Code: ______  Date of Diagnosis: ____________

 ;; ___ Other male reproductive system condition (specify diagnosis, providing

 ;;     only diagnoses that pertain to male reproductive system.)

 ;;                             ICD Code: ______  Date of Diagnosis: ____________

 ;;

 ;;    Other diagnosis #1: ____________________________

 ;;    ICD code: ______________________________________

 ;;    Date of diagnosis: _____________________________

 ;;^TOF^

 ;;    Other diagnosis #2: ____________________________

 ;;    ICD code: ______________________________________

 ;;    Date of diagnosis: _____________________________

 ;;

 ;; If there are additional diagnoses that pertain to the male reproductive organ

 ;; conditions, list using above format: ________________________________________

 ;;

 ;; 2. Medical history

 ;;

 ;; a. Describe the history (including onset and course) of the Veteran's male

 ;; reproductive organ condition(s) (brief summary): ____________________________

 ;;

 ;; b.  Does the Veteran's treatment plan include taking continuous medication

 ;; for the diagnosed condition?

 ;; ___ Yes   ___ No    List medications:  ______________________________________

 ;;

 ;; c.  Has the Veteran had an orchiectomy?

 ;; ___ Yes   ___ No

 ;;

 ;;    Indicate testicle removed:   ___ Right   ___ Left   ___ Both

 ;;

 ;;    Indicate reason for removal:

 ;;    ___ Undescended

 ;;    ___ Congenitally underdeveloped

 ;;    ___ Other: provide reason for removal: ___________________________________

 ;;

 ;; 3. Voiding dysfunction

 ;;

 ;; Does the Veteran have a voiding dysfunction?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, provide etiology of voiding dysfunction: ____________________________

 ;; If the Veteran has a voiding dysfunction, complete the following questions:

 ;;

 ;; a. Does the voiding dysfunction cause urine leakage?

 ;; ___ Yes   ___ No

 ;;

 ;; Indicate severity (check one):

 ;;

 ;;   ___ Does not require the wearing of absorbent material

 ;;   ___ Requires absorbent material which must be changed less than 2 times

 ;;       per day

 ;;   ___ Requires absorbent material which must be changed 2 to 4 times per day

 ;;   ___ Requires absorbent material which must be changed more than 4 times

 ;;       per day

 ;;   ___ Other, describe: ______________________________________________________

 ;;^TOF^

 ;; b. Does the voiding dysfunction require the use of an appliance?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, describe the appliance: _____________________________________________

 ;;

 ;; c. Does the  voiding dysfunction cause increased urinary frequency?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, check all that apply:

 ;;   ___ Daytime voiding interval between 2 and 3 hours

 ;;   ___ Daytime voiding interval between 1 and 2 hours

 ;;   ___ Daytime voiding interval less than 1 hour

 ;;   ___ Nighttime awakening to void 2 times

 ;;   ___ Nighttime awakening to void 3 to 4 times

 ;;   ___ Nighttime awakening to void 5 or more times

 ;;

 ;; d. Does the voiding dysfunction cause signs or symptoms of obstructed

 ;; voiding?

 ;;    ___ Yes   ___ No

 ;;

 ;; If yes, check all that apply:

 ;;    ___ Hesitancy

 ;;           If checked, is hesitancy marked?

 ;;           ___ Yes   ___ No

 ;;    ___ Slow or weak stream

 ;;           If checked, is stream markedly slow or weak?

 ;;           ___ Yes   ___ No

 ;;    ___ Decreased force of stream

 ;;           If checked, is force of stream markedly decreased?

 ;;           ___ Yes   ___ No

 ;;    ___ Stricture disease requiring dilatation 1 to 2 times per year

 ;;    ___ Stricture disease requiring periodic dilatation every 2 to 3 months

 ;;    ___ Recurrent urinary tract infections secondary to obstruction

 ;;    ___ Uroflowmetry peak flow rate less than 10 cc/sec

 ;;    ___ Post void residuals greater than 150 cc

 ;;    ___ Urinary retention requiring intermittent catheterization

 ;;    ___ Urinary retention requiring continuous catheterization

 ;;    ___ Other, describe: _____________________________________________________

 ;;^TOF^

 ;; 4. Urinary tract/kidney infection

 ;;

 ;; Does the Veteran have a history of recurrent symptomatic urinary tract

 ;; or kidney infections?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, provide etiology: ___________________________________________________

 ;;

 ;; If the Veteran has had recurrent symptomatic urinary tract or kidney

 ;; infections, indicate all treatment modalities that apply:

 ;;

 ;;    ___ No treatment

 ;;    ___ Long-term drug therapy

 ;;        If checked, list medications used and indicate dates for courses of

 ;;        treatment over the past 12 months: ___________________________________

 ;;    ___ Hospitalization

 ;;           If checked, indicate frequency of hospitalization:

 ;;           ___ 1 or 2 per year

 ;;           ___ > 2 per year

 ;;    ___ Drainage

 ;;        If checked, indicate dates when drainage performed over past 12

 ;;        months: ______________________

 ;;    ___ Continuous intensive management

 ;;        If checked, indicate types of treatment and medications used over past

 ;;        12 months: ___________________

 ;;    ___ Intermittent intensive management

 ;;        If checked, indicate types of treatment and medications used over past

 ;;        12 months: ___________________

 ;;    ___ Other, describe: _____________________________________________________

 ;;

 ;; 5. Erectile dysfunction

 ;;

 ;; a. Does the Veteran have erectile dysfunction?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, provide etiology:____________________________________________________

 ;;

 ;; b. If the Veteran has erectile dysfunction, is it as likely as not (at least

 ;; a 50% probability) attributable to one of the diagnoses in Section 1,

 ;; including residuals of treatment for this diagnosis?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, specify the diagnosis to which the erectile dysfunction is as likely

 ;; as not attributable: ________________________________________________________

 ;;^TOF^

 ;; c. If the Veteran has erectile dysfunction, is he able to achieve an erection

 ;; sufficient for penetration and ejaculation (without medication)?

 ;; ___ Yes   ___ No

 ;;

 ;; If no, is the Veteran able to achieve an erection sufficient for penetration

 ;; and ejaculation (with medication)?

 ;; ___ Yes   ___ No

 ;;

 ;; 6. Retrograde ejaculation

 ;;

 ;; a. Does the Veteran have retrograde ejaculation?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, provide etiology of the retrograde ejaculation:______________________

 ;;

 ;; b. If the Veteran has retrograde ejaculation, is it as likely as not (at

 ;; least a 50% probability) attributable to one of the diagnoses in Section 1,

 ;; including residuals of treatment for this diagnosis?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, specify the diagnosis to which the retrograde ejaculation is as

 ;; likely as not attributable: _________________________________________________

 ;;

 ;; 7. Male reproductive organ infections

 ;;

 ;; Does the Veteran have a history of chronic epididymitis, epididymo-orchitis

 ;; or prostatitis?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, indicate all treatment modalities that apply:

 ;;    ___ No treatment

 ;;    ___ Long-term drug therapy

 ;;        If checked, list medications used and indicate dates for courses of

 ;;        treatment over the past 12 months: ___________________________________

 ;;    ___ Hospitalization

 ;;        If checked, indicate frequency of hospitalization:

 ;;           ___ 1 or 2 per year

 ;;           ___ > 2 per year

 ;;    ___ Continuous intensive management

 ;;        If checked, indicate types of treatment and medications used over

 ;;        past 12 months: ______________________________________________________

 ;;    ___ Intermittent intensive management

 ;;        If checked, indicate types of treatment and medications used over

 ;;        past 12 months: ______________________________________________________

 ;;    ___ Other, describe: _____________________________________________________

 ;;^TOF^

 ;; 8. Physical exam

 ;;

 ;; a. Penis

 ;;       ___ Normal

 ;;       ___ Not examined per Veteran's request

 ;;       ___ Not examined; penis exam not relevant to condition

 ;;       ___ Abnormal

 ;;       If abnormal, indicate severity:

 ;;          ___ Loss/removal of half or more of penis

 ;;          ___ Loss/removal of glans penis

 ;;          ___ Penis deformity(such as Peyronie's disease)

 ;;              If checked, describe: _________________________

 ;;

 ;; b. Testes

 ;;       ___ Normal

 ;;       ___ Not examined per Veteran's request

 ;;       ___ Not examined; testicular exam not relevant to condition

 ;;       ___ Abnormal

 ;;

 ;;       If abnormal, check all that apply:

 ;;       Right testicle

 ;;          ___ Size 1/3 or less of normal

 ;;          ___ Size 1/2 to 1/3 of normal

 ;;          ___ Considerably harder than normal

 ;;          ___ Considerably softer than normal

 ;;          ___ Absent

 ;;          ___ Other abnormality,

 ;;              Describe: _____________________________________

 ;;

 ;;      Left testicle

 ;;          ___ Size 1/3 or less of normal

 ;;          ___ Size 1/2 to 1/3 of normal

 ;;          ___ Considerably harder than normal

 ;;          ___ Considerably softer than normal

 ;;          ___ Absent

 ;;          ___ Other abnormality,

 ;;              Describe: _____________________________________

 ;;^TOF^

 ;; c. Epididymis

 ;;       ___ Normal

 ;;       ___ Not examined per Veteran's request

 ;;       ___ Not examined; epididymis exam not relevant to condition

 ;;       ___ Abnormal

 ;;

 ;;       If abnormal, check all that apply:

 ;;       Right epididymis

 ;;          ___ Tender to palpation

 ;;          ___ Other, describe: ______________________________

 ;;

 ;;       Left epididymis

 ;;          ___ Tender to palpation

 ;;          ___ Other, describe: ______________________________

 ;;

 ;; d. Prostate

 ;;       ___ Normal

 ;;       ___ Not examined per Veteran's request

 ;;       ___ Not examined; prostate exam not relevant to condition

 ;;       ___ Abnormal

 ;;           If abnormal, describe: ___________________________

 ;;

 ;; 9. Tumors and neoplasms

 ;;

 ;; a.  Does the Veteran have a benign or malignant neoplasm or metastases

 ;; related to any of the diagnoses in the Diagnosis section?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, complete the following:

 ;;

 ;; b. Is the neoplasm

 ;; ___ Benign   ___ Malignant

 ;;^TOF^

 ;; c. Has the Veteran completed treatment or is the Veteran currently undergoing

 ;; treatment for a benign or malignant neoplasm or metastases?

 ;; ___ Yes   ___ No; watchful waiting

 ;;

 ;;    If yes, indicate type of treatment the Veteran is currently undergoing or

 ;;    has completed (check all that apply):

 ;;    ___ Treatment completed; currently in watchful waiting status

 ;;    ___ Surgery

 ;;           If checked, describe: _____________________________________________

 ;;           Date(s) of surgery:   ______________________________

 ;;    ___ Radiation therapy

 ;;           Date of most recent treatment: _____________________

 ;;           Date of completion of treatment or anticipated date of completion:

 ;;            ____________________

 ;;    ___ Antineoplastic chemotherapy

 ;;           Date of most recent treatment: _____________________

 ;;           Date of completion of treatment or anticipated date of completion:

 ;;           _____________________

 ;;    ___ Other therapeutic procedure

 ;;           If checked, describe procedure: ___________________________________

 ;;           Date of most recent procedure:  ____________________

 ;;    ___ Other therapeutic treatment

 ;;           If checked, describe treatment: ___________________________________

 ;;           Date of completion of treatment or anticipated date of completion:

 ;;           _____________________

 ;;

 ;; d. Does the Veteran currently have any residual conditions or complications

 ;; due to the neoplasm (including metastases) or its treatment, other than those

 ;; already documented in the report above?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, list residual conditions and complications (brief summary):

 ;; _____________________________________________________________________________

 ;;

 ;; e. If there are additional benign or malignant neoplasms or metastases

 ;; related to any of the diagnoses in the Diagnosis section, describe using the

 ;; above format: _______________________________________________________________

 ;;

 Q

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---DVBCQMR2   14692     printed  Mar 13, 2025@20:52                                                                                                                                                                                                      Page 2

DVBCQMR2  ;;ALB-CIOFO/ECF - MALE REPRODUCTIVE SYSTEM CONDITIONS QUESTIONNAIRE ; 2/15/2011

 +1       ;;2.7;AMIE;**163**;Apr 10, 1995;Build 5

 +2       ;

TXT       ;

 +1       ;;

 +2       ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for

 +3       ;; disability benefits.  VA will consider the information you provide on this

 +4       ;; questionnaire as part of their evaluation in processing the Veteran's claim.

 +5       ;;

 +6       ;; 1. Diagnosis:

 +7       ;;

 +8       ;; Does the Veteran now have or has he ever been diagnosed with any conditions

 +9       ;; of the male reproductive system?

 +10      ;; ___ Yes   ___ No

 +11      ;;

 +12      ;; If no, provide rationale (e.g., Veteran has never had  any known male

 +13      ;; reproductive organ conditions): _____________________________________________

 +14      ;;

 +15      ;; If yes, indicate diagnoses: (check all that apply)

 +16      ;; ___ Erectile dysfunction    ICD Code: ______  Date of Diagnosis: ____________

 +17      ;; ___ Penis, deformity (e.g., Peyronie's)

 +18      ;;                             ICD Code: ______  Date of Diagnosis: ____________

 +19      ;; ___ Testis, atrophy, one or both

 +20      ;;                             ICD Code: ______  Date of Diagnosis: ____________

 +21      ;; ___ Testis, removal, one or both

 +22      ;;                             ICD Code: ______  Date of Diagnosis: ____________

 +23      ;; ___ Epididymitis, chronic   ICD Code: ______  Date of Diagnosis: ____________

 +24      ;; ___ Epididymo-orchitis,  chronic

 +25      ;;                             ICD Code: ______  Date of Diagnosis: ____________

 +26      ;; ___ Prostate injury         ICD Code: ______  Date of Diagnosis: ____________

 +27      ;; ___ Prostate hypertrophy (BPH)

 +28      ;;                             ICD Code: ______  Date of Diagnosis: ____________

 +29      ;; ___ Prostatitis, chronic    ICD Code: ______  Date of Diagnosis: ____________

 +30      ;; ___ Prostate surgical residuals (as addressed in items 3-6)

 +31      ;;                             ICD Code: ______  Date of Diagnosis: ____________

 +32      ;; ___ Neoplasms of the male reproductive system

 +33      ;;                             ICD Code: ______  Date of Diagnosis: ____________

 +34      ;; ___ Other male reproductive system condition (specify diagnosis, providing

 +35      ;;     only diagnoses that pertain to male reproductive system.)

 +36      ;;                             ICD Code: ______  Date of Diagnosis: ____________

 +37      ;;

 +38      ;;    Other diagnosis #1: ____________________________

 +39      ;;    ICD code: ______________________________________

 +40      ;;    Date of diagnosis: _____________________________

 +41      ;;^TOF^

 +42      ;;    Other diagnosis #2: ____________________________

 +43      ;;    ICD code: ______________________________________

 +44      ;;    Date of diagnosis: _____________________________

 +45      ;;

 +46      ;; If there are additional diagnoses that pertain to the male reproductive organ

 +47      ;; conditions, list using above format: ________________________________________

 +48      ;;

 +49      ;; 2. Medical history

 +50      ;;

 +51      ;; a. Describe the history (including onset and course) of the Veteran's male

 +52      ;; reproductive organ condition(s) (brief summary): ____________________________

 +53      ;;

 +54      ;; b.  Does the Veteran's treatment plan include taking continuous medication

 +55      ;; for the diagnosed condition?

 +56      ;; ___ Yes   ___ No    List medications:  ______________________________________

 +57      ;;

 +58      ;; c.  Has the Veteran had an orchiectomy?

 +59      ;; ___ Yes   ___ No

 +60      ;;

 +61      ;;    Indicate testicle removed:   ___ Right   ___ Left   ___ Both

 +62      ;;

 +63      ;;    Indicate reason for removal:

 +64      ;;    ___ Undescended

 +65      ;;    ___ Congenitally underdeveloped

 +66      ;;    ___ Other: provide reason for removal: ___________________________________

 +67      ;;

 +68      ;; 3. Voiding dysfunction

 +69      ;;

 +70      ;; Does the Veteran have a voiding dysfunction?

 +71      ;; ___ Yes   ___ No

 +72      ;;

 +73      ;; If yes, provide etiology of voiding dysfunction: ____________________________

 +74      ;; If the Veteran has a voiding dysfunction, complete the following questions:

 +75      ;;

 +76      ;; a. Does the voiding dysfunction cause urine leakage?

 +77      ;; ___ Yes   ___ No

 +78      ;;

 +79      ;; Indicate severity (check one):

 +80      ;;

 +81      ;;   ___ Does not require the wearing of absorbent material

 +82      ;;   ___ Requires absorbent material which must be changed less than 2 times

 +83      ;;       per day

 +84      ;;   ___ Requires absorbent material which must be changed 2 to 4 times per day

 +85      ;;   ___ Requires absorbent material which must be changed more than 4 times

 +86      ;;       per day

 +87      ;;   ___ Other, describe: ______________________________________________________

 +88      ;;^TOF^

 +89      ;; b. Does the voiding dysfunction require the use of an appliance?

 +90      ;; ___ Yes   ___ No

 +91      ;;

 +92      ;; If yes, describe the appliance: _____________________________________________

 +93      ;;

 +94      ;; c. Does the  voiding dysfunction cause increased urinary frequency?

 +95      ;; ___ Yes   ___ No

 +96      ;;

 +97      ;; If yes, check all that apply:

 +98      ;;   ___ Daytime voiding interval between 2 and 3 hours

 +99      ;;   ___ Daytime voiding interval between 1 and 2 hours

 +100     ;;   ___ Daytime voiding interval less than 1 hour

 +101     ;;   ___ Nighttime awakening to void 2 times

 +102     ;;   ___ Nighttime awakening to void 3 to 4 times

 +103     ;;   ___ Nighttime awakening to void 5 or more times

 +104     ;;

 +105     ;; d. Does the voiding dysfunction cause signs or symptoms of obstructed

 +106     ;; voiding?

 +107     ;;    ___ Yes   ___ No

 +108     ;;

 +109     ;; If yes, check all that apply:

 +110     ;;    ___ Hesitancy

 +111     ;;           If checked, is hesitancy marked?

 +112     ;;           ___ Yes   ___ No

 +113     ;;    ___ Slow or weak stream

 +114     ;;           If checked, is stream markedly slow or weak?

 +115     ;;           ___ Yes   ___ No

 +116     ;;    ___ Decreased force of stream

 +117     ;;           If checked, is force of stream markedly decreased?

 +118     ;;           ___ Yes   ___ No

 +119     ;;    ___ Stricture disease requiring dilatation 1 to 2 times per year

 +120     ;;    ___ Stricture disease requiring periodic dilatation every 2 to 3 months

 +121     ;;    ___ Recurrent urinary tract infections secondary to obstruction

 +122     ;;    ___ Uroflowmetry peak flow rate less than 10 cc/sec

 +123     ;;    ___ Post void residuals greater than 150 cc

 +124     ;;    ___ Urinary retention requiring intermittent catheterization

 +125     ;;    ___ Urinary retention requiring continuous catheterization

 +126     ;;    ___ Other, describe: _____________________________________________________

 +127     ;;^TOF^

 +128     ;; 4. Urinary tract/kidney infection

 +129     ;;

 +130     ;; Does the Veteran have a history of recurrent symptomatic urinary tract

 +131     ;; or kidney infections?

 +132     ;; ___ Yes   ___ No

 +133     ;;

 +134     ;; If yes, provide etiology: ___________________________________________________

 +135     ;;

 +136     ;; If the Veteran has had recurrent symptomatic urinary tract or kidney

 +137     ;; infections, indicate all treatment modalities that apply:

 +138     ;;

 +139     ;;    ___ No treatment

 +140     ;;    ___ Long-term drug therapy

 +141     ;;        If checked, list medications used and indicate dates for courses of

 +142     ;;        treatment over the past 12 months: ___________________________________

 +143     ;;    ___ Hospitalization

 +144     ;;           If checked, indicate frequency of hospitalization:

 +145     ;;           ___ 1 or 2 per year

 +146     ;;           ___ > 2 per year

 +147     ;;    ___ Drainage

 +148     ;;        If checked, indicate dates when drainage performed over past 12

 +149     ;;        months: ______________________

 +150     ;;    ___ Continuous intensive management

 +151     ;;        If checked, indicate types of treatment and medications used over past

 +152     ;;        12 months: ___________________

 +153     ;;    ___ Intermittent intensive management

 +154     ;;        If checked, indicate types of treatment and medications used over past

 +155     ;;        12 months: ___________________

 +156     ;;    ___ Other, describe: _____________________________________________________

 +157     ;;

 +158     ;; 5. Erectile dysfunction

 +159     ;;

 +160     ;; a. Does the Veteran have erectile dysfunction?

 +161     ;; ___ Yes   ___ No

 +162     ;;

 +163     ;; If yes, provide etiology:____________________________________________________

 +164     ;;

 +165     ;; b. If the Veteran has erectile dysfunction, is it as likely as not (at least

 +166     ;; a 50% probability) attributable to one of the diagnoses in Section 1,

 +167     ;; including residuals of treatment for this diagnosis?

 +168     ;; ___ Yes   ___ No

 +169     ;;

 +170     ;; If yes, specify the diagnosis to which the erectile dysfunction is as likely

 +171     ;; as not attributable: ________________________________________________________

 +172     ;;^TOF^

 +173     ;; c. If the Veteran has erectile dysfunction, is he able to achieve an erection

 +174     ;; sufficient for penetration and ejaculation (without medication)?

 +175     ;; ___ Yes   ___ No

 +176     ;;

 +177     ;; If no, is the Veteran able to achieve an erection sufficient for penetration

 +178     ;; and ejaculation (with medication)?

 +179     ;; ___ Yes   ___ No

 +180     ;;

 +181     ;; 6. Retrograde ejaculation

 +182     ;;

 +183     ;; a. Does the Veteran have retrograde ejaculation?

 +184     ;; ___ Yes   ___ No

 +185     ;;

 +186     ;; If yes, provide etiology of the retrograde ejaculation:______________________

 +187     ;;

 +188     ;; b. If the Veteran has retrograde ejaculation, is it as likely as not (at

 +189     ;; least a 50% probability) attributable to one of the diagnoses in Section 1,

 +190     ;; including residuals of treatment for this diagnosis?

 +191     ;; ___ Yes   ___ No

 +192     ;;

 +193     ;; If yes, specify the diagnosis to which the retrograde ejaculation is as

 +194     ;; likely as not attributable: _________________________________________________

 +195     ;;

 +196     ;; 7. Male reproductive organ infections

 +197     ;;

 +198     ;; Does the Veteran have a history of chronic epididymitis, epididymo-orchitis

 +199     ;; or prostatitis?

 +200     ;; ___ Yes   ___ No

 +201     ;;

 +202     ;; If yes, indicate all treatment modalities that apply:

 +203     ;;    ___ No treatment

 +204     ;;    ___ Long-term drug therapy

 +205     ;;        If checked, list medications used and indicate dates for courses of

 +206     ;;        treatment over the past 12 months: ___________________________________

 +207     ;;    ___ Hospitalization

 +208     ;;        If checked, indicate frequency of hospitalization:

 +209     ;;           ___ 1 or 2 per year

 +210     ;;           ___ > 2 per year

 +211     ;;    ___ Continuous intensive management

 +212     ;;        If checked, indicate types of treatment and medications used over

 +213     ;;        past 12 months: ______________________________________________________

 +214     ;;    ___ Intermittent intensive management

 +215     ;;        If checked, indicate types of treatment and medications used over

 +216     ;;        past 12 months: ______________________________________________________

 +217     ;;    ___ Other, describe: _____________________________________________________

 +218     ;;^TOF^

 +219     ;; 8. Physical exam

 +220     ;;

 +221     ;; a. Penis

 +222     ;;       ___ Normal

 +223     ;;       ___ Not examined per Veteran's request

 +224     ;;       ___ Not examined; penis exam not relevant to condition

 +225     ;;       ___ Abnormal

 +226     ;;       If abnormal, indicate severity:

 +227     ;;          ___ Loss/removal of half or more of penis

 +228     ;;          ___ Loss/removal of glans penis

 +229     ;;          ___ Penis deformity(such as Peyronie's disease)

 +230     ;;              If checked, describe: _________________________

 +231     ;;

 +232     ;; b. Testes

 +233     ;;       ___ Normal

 +234     ;;       ___ Not examined per Veteran's request

 +235     ;;       ___ Not examined; testicular exam not relevant to condition

 +236     ;;       ___ Abnormal

 +237     ;;

 +238     ;;       If abnormal, check all that apply:

 +239     ;;       Right testicle

 +240     ;;          ___ Size 1/3 or less of normal

 +241     ;;          ___ Size 1/2 to 1/3 of normal

 +242     ;;          ___ Considerably harder than normal

 +243     ;;          ___ Considerably softer than normal

 +244     ;;          ___ Absent

 +245     ;;          ___ Other abnormality,

 +246     ;;              Describe: _____________________________________

 +247     ;;

 +248     ;;      Left testicle

 +249     ;;          ___ Size 1/3 or less of normal

 +250     ;;          ___ Size 1/2 to 1/3 of normal

 +251     ;;          ___ Considerably harder than normal

 +252     ;;          ___ Considerably softer than normal

 +253     ;;          ___ Absent

 +254     ;;          ___ Other abnormality,

 +255     ;;              Describe: _____________________________________

 +256     ;;^TOF^

 +257     ;; c. Epididymis

 +258     ;;       ___ Normal

 +259     ;;       ___ Not examined per Veteran's request

 +260     ;;       ___ Not examined; epididymis exam not relevant to condition

 +261     ;;       ___ Abnormal

 +262     ;;

 +263     ;;       If abnormal, check all that apply:

 +264     ;;       Right epididymis

 +265     ;;          ___ Tender to palpation

 +266     ;;          ___ Other, describe: ______________________________

 +267     ;;

 +268     ;;       Left epididymis

 +269     ;;          ___ Tender to palpation

 +270     ;;          ___ Other, describe: ______________________________

 +271     ;;

 +272     ;; d. Prostate

 +273     ;;       ___ Normal

 +274     ;;       ___ Not examined per Veteran's request

 +275     ;;       ___ Not examined; prostate exam not relevant to condition

 +276     ;;       ___ Abnormal

 +277     ;;           If abnormal, describe: ___________________________

 +278     ;;

 +279     ;; 9. Tumors and neoplasms

 +280     ;;

 +281     ;; a.  Does the Veteran have a benign or malignant neoplasm or metastases

 +282     ;; related to any of the diagnoses in the Diagnosis section?

 +283     ;; ___ Yes   ___ No

 +284     ;;

 +285     ;; If yes, complete the following:

 +286     ;;

 +287     ;; b. Is the neoplasm

 +288     ;; ___ Benign   ___ Malignant

 +289     ;;^TOF^

 +290     ;; c. Has the Veteran completed treatment or is the Veteran currently undergoing

 +291     ;; treatment for a benign or malignant neoplasm or metastases?

 +292     ;; ___ Yes   ___ No; watchful waiting

 +293     ;;

 +294     ;;    If yes, indicate type of treatment the Veteran is currently undergoing or

 +295     ;;    has completed (check all that apply):

 +296     ;;    ___ Treatment completed; currently in watchful waiting status

 +297     ;;    ___ Surgery

 +298     ;;           If checked, describe: _____________________________________________

 +299     ;;           Date(s) of surgery:   ______________________________

 +300     ;;    ___ Radiation therapy

 +301     ;;           Date of most recent treatment: _____________________

 +302     ;;           Date of completion of treatment or anticipated date of completion:

 +303     ;;            ____________________

 +304     ;;    ___ Antineoplastic chemotherapy

 +305     ;;           Date of most recent treatment: _____________________

 +306     ;;           Date of completion of treatment or anticipated date of completion:

 +307     ;;           _____________________

 +308     ;;    ___ Other therapeutic procedure

 +309     ;;           If checked, describe procedure: ___________________________________

 +310     ;;           Date of most recent procedure:  ____________________

 +311     ;;    ___ Other therapeutic treatment

 +312     ;;           If checked, describe treatment: ___________________________________

 +313     ;;           Date of completion of treatment or anticipated date of completion:

 +314     ;;           _____________________

 +315     ;;

 +316     ;; d. Does the Veteran currently have any residual conditions or complications

 +317     ;; due to the neoplasm (including metastases) or its treatment, other than those

 +318     ;; already documented in the report above?

 +319     ;; ___ Yes   ___ No

 +320     ;;

 +321     ;; If yes, list residual conditions and complications (brief summary):

 +322     ;; _____________________________________________________________________________

 +323     ;;

 +324     ;; e. If there are additional benign or malignant neoplasms or metastases

 +325     ;; related to any of the diagnoses in the Diagnosis section, describe using the

 +326     ;; above format: _______________________________________________________________

 +327     ;;

 +328      QUIT