Home   Package List   Routine Alphabetical List   Global Alphabetical List   FileMan Files List   FileMan Sub-Files List   Package Component Lists   Package-Namespace Mapping  
Routine: DVBCQMR3

DVBCQMR3.m

Go to the documentation of this file.
  1. DVBCQMR3 ;;ALB-CIOFO/ECF - MALE REPRODUCTIVE SYSTEM CONDITIONS QUESTIONNAIRE ; 2/15/2011
  1. ;;2.7;AMIE;**163**;Apr 10, 1995;Build 5
  1. ;
  1. TXT ;
  1. ;;
  1. ;;^TOF^
  1. ;; 10. Other pertinent physical findings, complications, conditions, signs
  1. ;; and/or symptoms
  1. ;;
  1. ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1. ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1. ;; section above?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, are any of the scars painful and/or unstable, or is the total area
  1. ;; of all related scars greater than 39 square cm (6 square inches)?
  1. ;; ___ Yes ___ No
  1. ;; If yes, also complete a Scars Questionnaire.
  1. ;;
  1. ;; b. Does the Veteran have any other pertinent physical findings,
  1. ;; complications, conditions, signs or symptoms?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, describe (brief summary): ___________________________________________
  1. ;;
  1. ;; 11. Diagnostic testing
  1. ;;
  1. ;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has
  1. ;; been performed and reflects the Veteran's current condition, provide most
  1. ;; recent results; no further studies or testing are required for this
  1. ;; examination.
  1. ;;
  1. ;; a. Has the Veteran had a testicular biopsy to determine the presence of
  1. ;; spermatozoa?
  1. ;; ___ Yes ___ No
  1. ;; If yes, were spermatozoa present?
  1. ;; ___ Yes ___ No
  1. ;; Date of biopsy: ________________
  1. ;;
  1. ;; b. Have any other imaging studies, diagnostic procedures or laboratory
  1. ;; testing been performed and are the results available?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, provide type of test or procedure, date and results (brief summary):
  1. ;; _____________________________________________________________________________
  1. ;;
  1. ;; 12. Functional impact
  1. ;;
  1. ;; Does the Veteran's male reproductive system condition(s), including neoplasms,
  1. ;; if any, impact his ability to work?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, describe the impact of each of the Veteran's male reproductive system
  1. ;; condition(s), providing one or more examples: _______________________________
  1. ;;^TOF^
  1. ;; 13. Remarks, if any: ________________________________________________________
  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. ;;
  1. ;;^END^
  1. Q