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 ---[H[J[2J[HDVBCQMR2 14692 printed Dec 13, 2024@01:47:18 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
