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
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQMR6 5283 printed Apr 09, 2024@20:56:59 Page 2
DVBCQMR6 ;;ALB-CIOFO/ECF - MALE REPRODUCTIVE SYSTEM CONDITIONS QUESTIONNAIRE (V3 continued); 6/15/2011
+1 ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
+2 ;
TXT ;
+1 ;;
+2 ;; 9. Tumors and neoplasms
+3 ;;
+4 ;; Does the Veteran have a benign or malignant neoplasm or metastases
+5 ;; related to any of the diagnoses in the Diagnosis section?
+6 ;; ___ Yes ___ No
+7 ;;
+8 ;; If yes, complete the following section:
+9 ;;
+10 ;; a. Is the neoplasm
+11 ;; ___ Benign ___ Malignant
+12 ;;^TOF^
+13 ;; b. Has the Veteran completed treatment or is the Veteran currently undergoing
+14 ;; treatment for a benign or malignant neoplasm or metastases?
+15 ;; ___ Yes ___ No; watchful waiting
+16 ;;
+17 ;; If yes, indicate type of treatment the Veteran is currently undergoing or
+18 ;; has completed (check all that apply):
+19 ;; ___ Treatment completed; currently in watchful waiting status
+20 ;; ___ Surgery
+21 ;; If checked, describe: _____________________________________________
+22 ;; Date(s) of surgery: ______________________________
+23 ;; ___ Radiation therapy
+24 ;; Date of most recent treatment: _____________________
+25 ;; Date of completion of treatment or anticipated date of completion:
+26 ;; ____________________
+27 ;; ___ Antineoplastic chemotherapy
+28 ;; Date of most recent treatment: _____________________
+29 ;; Date of completion of treatment or anticipated date of completion:
+30 ;; _____________________
+31 ;; ___ Other therapeutic procedure
+32 ;; If checked, describe procedure: ___________________________________
+33 ;; Date of most recent procedure: ____________________
+34 ;; ___ Other therapeutic treatment
+35 ;; If checked, describe treatment: ___________________________________
+36 ;; Date of completion of treatment or anticipated date of completion:
+37 ;; _____________________
+38 ;;
+39 ;; c. Does the Veteran currently have any residual conditions or complications
+40 ;; due to the neoplasm (including metastases) or its treatment, other than those
+41 ;; already documented in the report above?
+42 ;; ___ Yes ___ No
+43 ;;
+44 ;; If yes, list residual conditions and complications (brief summary):
+45 ;; _____________________________________________________________________________
+46 ;;
+47 ;; d. If there are additional benign or malignant neoplasms or metastases
+48 ;; related to any of the diagnoses in the Diagnosis section, describe using the
+49 ;; above format: _______________________________________________________________
+50 ;;^TOF^
+51 ;; 10. Other pertinent physical findings, complications, conditions, signs
+52 ;; and/or symptoms
+53 ;;
+54 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+55 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+56 ;; section above?
+57 ;; ___ Yes ___ No
+58 ;;
+59 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+60 ;; of all related scars greater than 39 square cm (6 square inches)?
+61 ;; ___ Yes ___ No
+62 ;; If yes, also complete a Scars Questionnaire.
+63 ;;
+64 ;; b. Does the Veteran have any other pertinent physical findings,
+65 ;; complications, conditions, signs or symptoms?
+66 ;; ___ Yes ___ No
+67 ;;
+68 ;; If yes, describe (brief summary): ___________________________________________
+69 ;;
+70 ;; 11. Diagnostic testing
+71 ;;
+72 ;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has
+73 ;; been performed and reflects the Veteran's current condition, provide most
+74 ;; recent results; no further studies or testing are required for this
+75 ;; examination. When appropriate, provide most recent results. No specific
+76 ;; studies are required for this examination.
+77 ;;
+78 ;; a. Has a testicular biopsy been performed?
+79 ;; ___ Yes ___ No
+80 ;; Date of biopsy: ________________
+81 ;; Results:
+82 ;; ___ Spermatozoa present
+83 ;; ___ Other, describe: _________________________
+84 ;;
+85 ;; b. Have any other imaging studies, diagnostic procedures or laboratory
+86 ;; testing been performed and are the results available?
+87 ;; ___ Yes ___ No
+88 ;;
+89 ;; If yes, provide type of test or procedure, date and results (brief summary):
+90 ;; ____________________________________________________________________________
+91 ;;
+92 ;; 12. Functional impact
+93 ;;
+94 ;; Does the Veteran's male reproductive system condition(s), including
+95 ;; neoplasms, if any, impact his ability to work?
+96 ;; ___ Yes ___ No
+97 ;;
+98 ;; If yes, describe the impact of each of the Veteran's male reproductive system
+99 ;; condition(s), providing one or more examples: ______________________________
+100 ;;^TOF^
+101 ;; 13. Remarks, if any: _______________________________________________________
+102 ;;
+103 ;; Physician signature: ____________________________________ Date: ____________
+104 ;;
+105 ;; Physician printed name: _________________________________ Phone: ___________
+106 ;;
+107 ;; Medical license #: ______________________________________ Fax: _____________
+108 ;;
+109 ;; Physician address: _________________________________________________________
+110 ;;
+111 ;; NOTE: VA may request additional medical information, including additional
+112 ;; examinations if necessary to complete VA's review of the Veteran's
+113 ;; application.
+114 ;;
+115 ;;^END^
+116 QUIT
