DVBCQMR5.m

DVBCQMR5 ;;ALB-CIOFO/ECF - MALE REPRODUCTIVE SYSTEM CONDITIONS QUESTIONNAIRE (V3); 6/15/2011

 ;;2.7;AMIE;**169**;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 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 taken for the diagnosed condition:  _______________________

 ;;

 ;; 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, complete the following section:

 ;;

 ;; a. Etiology of voiding dysfunction: ____________________________

 ;;

 ;; b. 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^

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

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, describe the appliance: _____________________________________________

 ;;

 ;; d. 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

 ;;

 ;; e. 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, complete the following section:

 ;;

 ;; a. Etiology of recurrent urinary tract or kidney infections:  ______________

 ;; ____________________________________________________________________________

 ;;

 ;; b. Indicate all treatment modalities used for recurrent urinary tract or

 ;; kidney infections (check all 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

 ;;

 ;; Does the Veteran have erectile dysfunction?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, complete the following section:

 ;;

 ;; a. Etiology of erectile dysfunction: _______________________________________

 ;; ____________________________________________________________________________

 ;;

 ;; 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

 ;;

 ;; Does the Veteran have retrograde ejaculation?

 ;; ___ Yes   ___ No

 ;; If yes, complete the following section:

 ;;

 ;; a. Etiology of 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 used for chronic epididymitis,

 ;; epididymo-orchitis or prostatitis (check all 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 per Veteran's request; Veteran reports normal anatomy

 ;;           with no penile deformity or abnormality 

 ;;       ___ 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 per Veteran's request; Veteran reports normal anatomy

 ;;           with no testicular deformity or abnormality 

 ;;       ___ 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 per Veteran's request; Veteran reports normal anatomy

 ;;           of epididymis with no deformity or abnormality  

 ;;       ___ 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: ___________________________

 ;;

 Q

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---DVBCQMR5   12947     printed  Feb 18, 2025@23:13:46                                                                                                                                                                                                   Page 2

DVBCQMR5  ;;ALB-CIOFO/ECF - MALE REPRODUCTIVE SYSTEM CONDITIONS QUESTIONNAIRE (V3); 6/15/2011

 +1       ;;2.7;AMIE;**169**;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 yes, indicate diagnoses: (check all that apply)

 +13      ;; ___ Erectile dysfunction    ICD code: ______  Date of diagnosis: ____________

 +14      ;; ___ Penis, deformity (e.g., Peyronie's)

 +15      ;;                             ICD code: ______  Date of diagnosis: ____________

 +16      ;; ___ Testis, atrophy, one or both

 +17      ;;                             ICD code: ______  Date of diagnosis: ____________

 +18      ;; ___ Testis, removal, one or both

 +19      ;;                             ICD code: ______  Date of diagnosis: ____________

 +20      ;; ___ Epididymitis, chronic   ICD code: ______  Date of diagnosis: ____________

 +21      ;; ___ Epididymo-orchitis,  chronic

 +22      ;;                             ICD code: ______  Date of diagnosis: ____________

 +23      ;; ___ Prostate injury         ICD code: ______  Date of diagnosis: ____________

 +24      ;; ___ Prostate hypertrophy (BPH)

 +25      ;;                             ICD code: ______  Date of diagnosis: ____________

 +26      ;; ___ Prostatitis, chronic    ICD code: ______  Date of diagnosis: ____________

 +27      ;; ___ Prostate surgical residuals (as addressed in items 3-6)

 +28      ;;                             ICD code: ______  Date of diagnosis: ____________

 +29      ;; ___ Neoplasms of the male reproductive system

 +30      ;;                             ICD code: ______  Date of diagnosis: ____________

 +31      ;; ___ Other male reproductive system condition (specify diagnosis, providing

 +32      ;;     only diagnoses that pertain to male reproductive system.)

 +33      ;;                             ICD code: ______  Date of diagnosis: ____________

 +34      ;;

 +35      ;;    Other diagnosis #1: ____________________________

 +36      ;;    ICD code: ______________________________________

 +37      ;;    Date of diagnosis: _____________________________

 +38      ;;^TOF^

 +39      ;;    Other diagnosis #2: ____________________________

 +40      ;;    ICD code: ______________________________________

 +41      ;;    Date of diagnosis: _____________________________

 +42      ;;

 +43      ;; If there are additional diagnoses that pertain to the male reproductive organ

 +44      ;; conditions, list using above format: ________________________________________

 +45      ;;

 +46      ;; 2. Medical history

 +47      ;;

 +48      ;; a. Describe the history (including onset and course) of the Veteran's male

 +49      ;; reproductive organ condition(s) (brief summary): ____________________________

 +50      ;;

 +51      ;; b. Does the Veteran's treatment plan include taking continuous medication

 +52      ;; for the diagnosed condition?

 +53      ;; ___ Yes   ___ No

 +54      ;; List medications taken for the diagnosed condition:  _______________________

 +55      ;;

 +56      ;; c. Has the Veteran had an orchiectomy?

 +57      ;; ___ Yes   ___ No

 +58      ;;

 +59      ;;    Indicate testicle removed:   ___ Right   ___ Left   ___ Both

 +60      ;;

 +61      ;;    Indicate reason for removal:

 +62      ;;    ___ Undescended

 +63      ;;    ___ Congenitally underdeveloped

 +64      ;;    ___ Other, provide reason for removal: ___________________________________

 +65      ;;

 +66      ;; 3. Voiding dysfunction

 +67      ;;

 +68      ;; Does the Veteran have a voiding dysfunction?

 +69      ;; ___ Yes   ___ No

 +70      ;; If yes, complete the following section:

 +71      ;;

 +72      ;; a. Etiology of voiding dysfunction: ____________________________

 +73      ;;

 +74      ;; b. Does the voiding dysfunction cause urine leakage?

 +75      ;; ___ Yes   ___ No

 +76      ;; Indicate severity (check one):

 +77      ;;

 +78      ;;   ___ Does not require the wearing of absorbent material

 +79      ;;   ___ Requires absorbent material which must be changed less than 2 times

 +80      ;;       per day

 +81      ;;   ___ Requires absorbent material which must be changed 2 to 4 times per day

 +82      ;;   ___ Requires absorbent material which must be changed more than 4 times

 +83      ;;       per day

 +84      ;;   ___ Other, describe: ______________________________________________________

 +85      ;;^TOF^

 +86      ;; c. Does the voiding dysfunction require the use of an appliance?

 +87      ;; ___ Yes   ___ No

 +88      ;;

 +89      ;; If yes, describe the appliance: _____________________________________________

 +90      ;;

 +91      ;; d. Does the  voiding dysfunction cause increased urinary frequency?

 +92      ;; ___ Yes   ___ No

 +93      ;;

 +94      ;; If yes, check all that apply:

 +95      ;;   ___ Daytime voiding interval between 2 and 3 hours

 +96      ;;   ___ Daytime voiding interval between 1 and 2 hours

 +97      ;;   ___ Daytime voiding interval less than 1 hour

 +98      ;;   ___ Nighttime awakening to void 2 times

 +99      ;;   ___ Nighttime awakening to void 3 to 4 times

 +100     ;;   ___ Nighttime awakening to void 5 or more times

 +101     ;;

 +102     ;; e. Does the voiding dysfunction cause signs or symptoms of obstructed

 +103     ;; voiding?

 +104     ;;    ___ Yes   ___ No

 +105     ;;

 +106     ;; If yes, check all that apply:

 +107     ;;    ___ Hesitancy

 +108     ;;           If checked, is hesitancy marked?

 +109     ;;           ___ Yes   ___ No

 +110     ;;    ___ Slow or weak stream

 +111     ;;           If checked, is stream markedly slow or weak?

 +112     ;;           ___ Yes   ___ No

 +113     ;;    ___ Decreased force of stream

 +114     ;;           If checked, is force of stream markedly decreased?

 +115     ;;           ___ Yes   ___ No

 +116     ;;    ___ Stricture disease requiring dilatation 1 to 2 times per year

 +117     ;;    ___ Stricture disease requiring periodic dilatation every 2 to 3 months

 +118     ;;    ___ Recurrent urinary tract infections secondary to obstruction

 +119     ;;    ___ Uroflowmetry peak flow rate less than 10 cc/sec

 +120     ;;    ___ Post void residuals greater than 150 cc

 +121     ;;    ___ Urinary retention requiring intermittent catheterization

 +122     ;;    ___ Urinary retention requiring continuous catheterization

 +123     ;;    ___ Other, describe: _____________________________________________________

 +124     ;;^TOF^

 +125     ;; 4. Urinary tract/kidney infection

 +126     ;;

 +127     ;; Does the Veteran have a history of recurrent symptomatic urinary tract

 +128     ;; or kidney infections?

 +129     ;; ___ Yes   ___ No

 +130     ;; If yes, complete the following section:

 +131     ;;

 +132     ;; a. Etiology of recurrent urinary tract or kidney infections:  ______________

 +133     ;; ____________________________________________________________________________

 +134     ;;

 +135     ;; b. Indicate all treatment modalities used for recurrent urinary tract or

 +136     ;; kidney infections (check all that apply):

 +137     ;;

 +138     ;;    ___ No treatment

 +139     ;;    ___ Long-term drug therapy

 +140     ;;        If checked, list medications used and indicate dates for courses of

 +141     ;;        treatment over the past 12 months: ___________________________________

 +142     ;;    ___ Hospitalization

 +143     ;;           If checked, indicate frequency of hospitalization:

 +144     ;;           ___ 1 or 2 per year

 +145     ;;           ___ > 2 per year

 +146     ;;    ___ Drainage

 +147     ;;        If checked, indicate dates when drainage performed over past 12

 +148     ;;        months: ______________________

 +149     ;;    ___ Continuous intensive management

 +150     ;;        If checked, indicate types of treatment and medications used over past

 +151     ;;        12 months: ___________________

 +152     ;;    ___ Intermittent intensive management

 +153     ;;        If checked, indicate types of treatment and medications used over past

 +154     ;;        12 months: ___________________

 +155     ;;    ___ Other, describe: _____________________________________________________

 +156     ;;

 +157     ;; 5. Erectile dysfunction

 +158     ;;

 +159     ;; Does the Veteran have erectile dysfunction?

 +160     ;; ___ Yes   ___ No

 +161     ;;

 +162     ;; If yes, complete the following section:

 +163     ;;

 +164     ;; a. Etiology of erectile dysfunction: _______________________________________

 +165     ;; ____________________________________________________________________________

 +166     ;;

 +167     ;; b. If the Veteran has erectile dysfunction, is it as likely as not (at least

 +168     ;; a 50% probability) attributable to one of the diagnoses in Section 1,

 +169     ;; including residuals of treatment for this diagnosis?

 +170     ;; ___ Yes   ___ No

 +171     ;;

 +172     ;; If yes, specify the diagnosis to which the erectile dysfunction is as likely

 +173     ;; as not attributable: ________________________________________________________

 +174     ;;^TOF^

 +175     ;; c. If the Veteran has erectile dysfunction, is he able to achieve an erection

 +176     ;; sufficient for penetration and ejaculation (without medication)?

 +177     ;; ___ Yes   ___ No

 +178     ;;

 +179     ;; If no, is the Veteran able to achieve an erection sufficient for penetration

 +180     ;; and ejaculation (with medication)?

 +181     ;; ___ Yes   ___ No

 +182     ;;

 +183     ;; 6. Retrograde ejaculation

 +184     ;;

 +185     ;; Does the Veteran have retrograde ejaculation?

 +186     ;; ___ Yes   ___ No

 +187     ;; If yes, complete the following section:

 +188     ;;

 +189     ;; a. Etiology of retrograde ejaculation: ______________________

 +190     ;;

 +191     ;; b. If the Veteran has retrograde ejaculation, is it as likely as not (at

 +192     ;; least a 50% probability) attributable to one of the diagnoses in Section 1,

 +193     ;; including residuals of treatment for this diagnosis?

 +194     ;; ___ Yes   ___ No

 +195     ;;

 +196     ;; If yes, specify the diagnosis to which the retrograde ejaculation is as

 +197     ;; likely as not attributable: _________________________________________________

 +198     ;;

 +199     ;; 7. Male reproductive organ infections

 +200     ;;

 +201     ;; Does the Veteran have a history of chronic epididymitis, epididymo-orchitis

 +202     ;; or prostatitis?

 +203     ;; ___ Yes   ___ No

 +204     ;;

 +205     ;; If yes, indicate all treatment modalities used for chronic epididymitis,

 +206     ;; epididymo-orchitis or prostatitis (check all that apply):

 +207     ;;    ___ No treatment

 +208     ;;    ___ Long-term drug therapy

 +209     ;;        If checked, list medications used and indicate dates for courses of

 +210     ;;        treatment over the past 12 months: ___________________________________

 +211     ;;    ___ Hospitalization

 +212     ;;        If checked, indicate frequency of hospitalization:

 +213     ;;           ___ 1 or 2 per year

 +214     ;;           ___ > 2 per year

 +215     ;;    ___ Continuous intensive management

 +216     ;;        If checked, indicate types of treatment and medications used over

 +217     ;;        past 12 months: ______________________________________________________

 +218     ;;    ___ Intermittent intensive management

 +219     ;;        If checked, indicate types of treatment and medications used over

 +220     ;;        past 12 months: ______________________________________________________

 +221     ;;    ___ Other, describe: _____________________________________________________

 +222     ;;^TOF^

 +223     ;; 8. Physical exam

 +224     ;;

 +225     ;; a. Penis

 +226     ;;       ___ Normal

 +227     ;;       ___ Not examined per Veteran's request

 +228     ;;       ___ Not examined per Veteran's request; Veteran reports normal anatomy

 +229     ;;           with no penile deformity or abnormality 

 +230     ;;       ___ Not examined; penis exam not relevant to condition

 +231     ;;       ___ Abnormal

 +232     ;;       If abnormal, indicate severity:

 +233     ;;          ___ Loss/removal of half or more of penis

 +234     ;;          ___ Loss/removal of glans penis

 +235     ;;          ___ Penis deformity(such as Peyronie's disease)

 +236     ;;              If checked, describe: _________________________

 +237     ;;

 +238     ;; b. Testes

 +239     ;;       ___ Normal

 +240     ;;       ___ Not examined per Veteran's request

 +241     ;;       ___ Not examined per Veteran's request; Veteran reports normal anatomy

 +242     ;;           with no testicular deformity or abnormality 

 +243     ;;       ___ Not examined; testicular exam not relevant to condition

 +244     ;;       ___ Abnormal

 +245     ;;

 +246     ;;           If abnormal, check all that apply:

 +247     ;;           Right testicle

 +248     ;;              ___ Size 1/3 or less of normal

 +249     ;;              ___ Size 1/2 to 1/3 of normal

 +250     ;;              ___ Considerably harder than normal

 +251     ;;              ___ Considerably softer than normal

 +252     ;;              ___ Absent

 +253     ;;              ___ Other abnormality,

 +254     ;;                  Describe: _____________________________________

 +255     ;;

 +256     ;;           Left testicle

 +257     ;;              ___ Size 1/3 or less of normal

 +258     ;;              ___ Size 1/2 to 1/3 of normal

 +259     ;;              ___ Considerably harder than normal

 +260     ;;              ___ Considerably softer than normal

 +261     ;;              ___ Absent

 +262     ;;              ___ Other abnormality,

 +263     ;;                  Describe: _____________________________________

 +264     ;;^TOF^

 +265     ;; c. Epididymis

 +266     ;;       ___ Normal

 +267     ;;       ___ Not examined per Veteran's request

 +268     ;;       ___ Not examined per Veteran's request; Veteran reports normal anatomy

 +269     ;;           of epididymis with no deformity or abnormality  

 +270     ;;       ___ Not examined; epididymis exam not relevant to condition

 +271     ;;       ___ Abnormal

 +272     ;;

 +273     ;;       If abnormal, check all that apply:

 +274     ;;       Right epididymis

 +275     ;;          ___ Tender to palpation

 +276     ;;          ___ Other, describe: ______________________________

 +277     ;;

 +278     ;;       Left epididymis

 +279     ;;          ___ Tender to palpation

 +280     ;;          ___ Other, describe: ______________________________

 +281     ;;

 +282     ;; d. Prostate

 +283     ;;       ___ Normal

 +284     ;;       ___ Not examined per Veteran's request

 +285     ;;       ___ Not examined; prostate exam not relevant to condition

 +286     ;;       ___ Abnormal

 +287     ;;           If abnormal, describe: ___________________________

 +288     ;;

 +289      QUIT