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Routine: DVBCQMR6

DVBCQMR6.m

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  1. DVBCQMR6 ;;ALB-CIOFO/ECF - MALE REPRODUCTIVE SYSTEM CONDITIONS QUESTIONNAIRE (V3 continued); 6/15/2011
  1.  ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; 9. Tumors and neoplasms
  1.  ;;
  1.  ;; Does the Veteran have a benign or malignant neoplasm or metastases
  1.  ;; related to any of the diagnoses in the Diagnosis section?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, complete the following section:
  1.  ;;
  1.  ;; a. Is the neoplasm
  1.  ;; ___ Benign   ___ Malignant
  1.  ;;^TOF^
  1.  ;; b. Has the Veteran completed treatment or is the Veteran currently undergoing
  1.  ;; treatment for a benign or malignant neoplasm or metastases?
  1.  ;; ___ Yes   ___ No; watchful waiting
  1.  ;;
  1.  ;;    If yes, indicate type of treatment the Veteran is currently undergoing or
  1.  ;;    has completed (check all that apply):
  1.  ;;    ___ Treatment completed; currently in watchful waiting status
  1.  ;;    ___ Surgery
  1.  ;;           If checked, describe: _____________________________________________
  1.  ;;           Date(s) of surgery:   ______________________________
  1.  ;;    ___ Radiation therapy
  1.  ;;           Date of most recent treatment: _____________________
  1.  ;;           Date of completion of treatment or anticipated date of completion:
  1.  ;;            ____________________
  1.  ;;    ___ Antineoplastic chemotherapy
  1.  ;;           Date of most recent treatment: _____________________
  1.  ;;           Date of completion of treatment or anticipated date of completion:
  1.  ;;           _____________________
  1.  ;;    ___ Other therapeutic procedure
  1.  ;;           If checked, describe procedure: ___________________________________
  1.  ;;           Date of most recent procedure:  ____________________
  1.  ;;    ___ Other therapeutic treatment
  1.  ;;           If checked, describe treatment: ___________________________________
  1.  ;;           Date of completion of treatment or anticipated date of completion:
  1.  ;;           _____________________
  1.  ;;
  1.  ;; c. Does the Veteran currently have any residual conditions or complications
  1.  ;; due to the neoplasm (including metastases) or its treatment, other than those
  1.  ;; already documented in the report above?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, list residual conditions and complications (brief summary):
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; d. If there are additional benign or malignant neoplasms or metastases
  1.  ;; related to any of the diagnoses in the Diagnosis section, describe using the
  1.  ;; above format: _______________________________________________________________ 
  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.  When appropriate, provide most recent results. No specific
  1.  ;; studies are required for this examination.
  1.  ;;
  1.  ;; a. Has a testicular biopsy been performed?
  1.  ;; ___ Yes   ___ No
  1.  ;;    Date of biopsy: ________________
  1.  ;;    Results:
  1.  ;;       ___ Spermatozoa present
  1.  ;;       ___ Other, describe: _________________________
  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
  1.  ;; neoplasms, 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