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Routine: DVBCQMR6

DVBCQMR6.m

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DVBCQMR6 ;;ALB-CIOFO/ECF - MALE REPRODUCTIVE SYSTEM CONDITIONS QUESTIONNAIRE (V3 continued); 6/15/2011
 ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
 ;
TXT ;
 ;;
 ;; 9. Tumors and neoplasms
 ;;
 ;; 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 section:
 ;;
 ;; a. Is the neoplasm
 ;; ___ Benign   ___ Malignant
 ;;^TOF^
 ;; b. 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:
 ;;           _____________________
 ;;
 ;; c. 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):
 ;; _____________________________________________________________________________
 ;;
 ;; d. 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: _______________________________________________________________ 
 ;;^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.  When appropriate, provide most recent results. No specific
 ;; studies are required for this examination.
 ;;
 ;; a. Has a testicular biopsy been performed?
 ;; ___ Yes   ___ No
 ;;    Date of biopsy: ________________
 ;;    Results:
 ;;       ___ Spermatozoa present
 ;;       ___ Other, describe: _________________________
 ;;
 ;; 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