- 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 Feb 18, 2025@23:13:45 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