DVBCQMR3 ;;ALB-CIOFO/ECF - MALE REPRODUCTIVE SYSTEM CONDITIONS QUESTIONNAIRE ; 2/15/2011
;;2.7;AMIE;**163**;Apr 10, 1995;Build 5
;
TXT ;
;;
;;^TOF^
;; 10. 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 or symptoms?
;; ___ Yes ___ No
;;
;; If yes, describe (brief summary): ___________________________________________
;;
;; 11. Diagnostic testing
;;
;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has
;; been performed and reflects the Veteran's current condition, provide most
;; recent results; no further studies or testing are required for this
;; examination.
;;
;; a. Has the Veteran had a testicular biopsy to determine the presence of
;; spermatozoa?
;; ___ Yes ___ No
;; If yes, were spermatozoa present?
;; ___ Yes ___ No
;; Date of biopsy: ________________
;;
;; b. Have any other imaging studies, diagnostic procedures or laboratory
;; testing been performed and are the results available?
;; ___ Yes ___ No
;;
;; If yes, provide type of test or procedure, date and results (brief summary):
;; _____________________________________________________________________________
;;
;; 12. Functional impact
;;
;; Does the Veteran's male reproductive system condition(s), including neoplasms,
;; if any, impact his ability to work?
;; ___ Yes ___ No
;;
;; If yes, describe the impact of each of the Veteran's male reproductive system
;; condition(s), providing one or more examples: _______________________________
;;^TOF^
;; 13. Remarks, if any: ________________________________________________________
;;
;; Physician signature: _____________________________________ Date: ____________
;;
;; Physician printed name: __________________________________ Phone: ___________
;;
;; Medical license #: _______________________________________ Fax: _____________
;;
;; Physician address: __________________________________________________________
;;
;; NOTE: VA may request additional medical information, including additional
;; examinations if necessary to complete VA's review of the Veteran's
;; application.
;;
;;^END^
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQMR3 2778 printed Dec 13, 2024@01:47:19 Page 2
DVBCQMR3 ;;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 ;;^TOF^
+3 ;; 10. Other pertinent physical findings, complications, conditions, signs
+4 ;; and/or symptoms
+5 ;;
+6 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+7 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+8 ;; section above?
+9 ;; ___ Yes ___ No
+10 ;;
+11 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+12 ;; of all related scars greater than 39 square cm (6 square inches)?
+13 ;; ___ Yes ___ No
+14 ;; If yes, also complete a Scars Questionnaire.
+15 ;;
+16 ;; b. Does the Veteran have any other pertinent physical findings,
+17 ;; complications, conditions, signs or symptoms?
+18 ;; ___ Yes ___ No
+19 ;;
+20 ;; If yes, describe (brief summary): ___________________________________________
+21 ;;
+22 ;; 11. Diagnostic testing
+23 ;;
+24 ;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has
+25 ;; been performed and reflects the Veteran's current condition, provide most
+26 ;; recent results; no further studies or testing are required for this
+27 ;; examination.
+28 ;;
+29 ;; a. Has the Veteran had a testicular biopsy to determine the presence of
+30 ;; spermatozoa?
+31 ;; ___ Yes ___ No
+32 ;; If yes, were spermatozoa present?
+33 ;; ___ Yes ___ No
+34 ;; Date of biopsy: ________________
+35 ;;
+36 ;; b. Have any other imaging studies, diagnostic procedures or laboratory
+37 ;; testing been performed and are the results available?
+38 ;; ___ Yes ___ No
+39 ;;
+40 ;; If yes, provide type of test or procedure, date and results (brief summary):
+41 ;; _____________________________________________________________________________
+42 ;;
+43 ;; 12. Functional impact
+44 ;;
+45 ;; Does the Veteran's male reproductive system condition(s), including neoplasms,
+46 ;; if any, impact his ability to work?
+47 ;; ___ Yes ___ No
+48 ;;
+49 ;; If yes, describe the impact of each of the Veteran's male reproductive system
+50 ;; condition(s), providing one or more examples: _______________________________
+51 ;;^TOF^
+52 ;; 13. Remarks, if any: ________________________________________________________
+53 ;;
+54 ;; Physician signature: _____________________________________ Date: ____________
+55 ;;
+56 ;; Physician printed name: __________________________________ Phone: ___________
+57 ;;
+58 ;; Medical license #: _______________________________________ Fax: _____________
+59 ;;
+60 ;; Physician address: __________________________________________________________
+61 ;;
+62 ;; NOTE: VA may request additional medical information, including additional
+63 ;; examinations if necessary to complete VA's review of the Veteran's
+64 ;; application.
+65 ;;
+66 ;;^END^
+67 QUIT
