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Routine: DVBCQOS2

DVBCQOS2.m

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  1. DVBCQOS2 ;;ALB-CIOFO/ECF - OSTEOMYELITIS QUESTIONNAIRE ; 6/20/2010
  1.  ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA)
  1.  ;; for disability benefits.  VA will consider the information you provide on
  1.  ;; this questionnaire as part of their evaluation in processing the Veteran's
  1.  ;; claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with
  1.  ;; osteomyelitis?
  1.  ;; ___ Yes ___ No
  1.  ;;
  1.  ;; If yes, provide only diagnoses that pertain to osteomyelitis:
  1.  ;; Diagnosis #1: ____________________
  1.  ;; ICD code: ________________________
  1.  ;; Date of diagnosis: _______________
  1.  ;;
  1.  ;; Diagnosis #2: ____________________
  1.  ;; ICD code: ________________________
  1.  ;; Date of diagnosis: _______________
  1.  ;;
  1.  ;; Diagnosis #3: ____________________
  1.  ;; ICD code: ________________________
  1.  ;; Date of diagnosis: _______________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to osteomyelitis, list using
  1.  ;; above format: ______________________________________________________________
  1.  ;;
  1.  ;; 2. Medical History
  1.  ;;
  1.  ;; a. Describe the history (including onset and course) of the Veteran's
  1.  ;; osteomyelitis (brief summary): _____________________________________________
  1.  ;;
  1.  ;; b. Indicate location of initial infection (check all that apply):
  1.  ;;    ___ Pelvis
  1.  ;;    ___ Cervical vertebrae
  1.  ;;    ___ Thoracolumbar vertebrae
  1.  ;;    ___ Long bones of upper extremity
  1.  ;;        Side affected: ___ Right   ___ Left
  1.  ;;    ___ Long bones of lower extremity
  1.  ;;        Side affected: ___ Right   ___ Left
  1.  ;;    ___ Finger(s): ___ Right, digit(s) affected _____________________________
  1.  ;;                   ___ Left, digit(s) affected ______________________________
  1.  ;;    ___ Toe(s):    ___ Right, digit(s) affected _____________________________
  1.  ;;                   ___ Left, digit(s) affected ______________________________
  1.  ;;    ___ Other, specify: _____________________________________________________
  1.  ;;^TOF^
  1.  ;;    ___ Extension into joints
  1.  ;;        If checked, indicate joints affected:
  1.  ;;        Right: ___ Shoulder    ___ Elbow    ___ Wrist     ___ Hip    ___ Knee
  1.  ;;               ___ Ankle  ___ Multiple hand joints   ___ Multiple foot joints
  1.  ;;        Left:  ___ Shoulder    ___ Elbow    ___ Wrist     ___ Hip    ___ Knee
  1.  ;;               ___ Ankle  ___ Multiple hand joints   ___ Multiple foot joints
  1.  ;;        ___ Other, specify: _________________________________________________
  1.  ;;
  1.  ;; c. Has the Veteran had medical treatment or is the Veteran currently
  1.  ;; undergoing medical treatment for osteomyelitis?
  1.  ;; ___ Yes ___ No
  1.  ;;    If yes, describe treatment:______________________________________________
  1.  ;;    Date treatment started: _________________________________________________
  1.  ;; Date treatment completed or anticipated date of completion: ________________
  1.  ;;
  1.  ;; d. Has the Veteran had surgical treatment for osteomyelitis?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, indicate surgical procedure and date (if multiple procedures,
  1.  ;; indicate below):
  1.  ;;   Procedure #1: ____________________________________________________________
  1.  ;;   Date: ____________________________________________________________________
  1.  ;;   Facility: ________________________________________________________________
  1.  ;;
  1.  ;;   Procedure #2: ____________________________________________________________
  1.  ;;   Date: ___________________
  1.  ;;   Facility: ________________________________________________________________
  1.  ;;
  1.  ;;   If additional surgical procedures, list, using above format: _____________
  1.  ;;
  1.  ;; e. Provide status of the Veteran's current osteomyelitis condition:
  1.  ;; ___ Acute  ___ Subacute   ___ Chronic     ___ Inactive    ___ Resolved
  1.  ;; ___ Other: describe: _______________________________________________________
  1.  ;;
  1.  ;; 3. Recurrent infections
  1.  ;;
  1.  ;; a. Has the Veteran had any additional episodes or recurring infections of
  1.  ;; osteomyelitis following the initial infection?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, indicate number of additional episodes:
  1.  ;;    ___ 1   ___ 2   ___ 3   ___ 4   ___ 5 or more
  1.  ;;^TOF^
  1.  ;; b. Location of recurrent infections (check all that apply):
  1.  ;;    ___ Pelvis
  1.  ;;    ___ Cervical vertebrae
  1.  ;;    ___ Thoracolumbar vertebrae
  1.  ;;    ___ Long bones of upper extremity
  1.  ;;        Side affected:   ___ Right   ___ Left
  1.  ;;    ___ Long bones of lower extremity
  1.  ;;        Side affected:   ___ Right   ___ Left
  1.  ;;    ___ Finger(s):   ___ Right, digit(s) affected ___________________________
  1.  ;;                     ___ Left, digit(s) affected ____________________________
  1.  ;;    ___ Toe(s):      ___ Right, digit(s) affected ___________________________
  1.  ;;                     ___ Left, digit(s) affected ____________________________
  1.  ;;    ___ Other, specify: _____________________________________________________
  1.  ;;
  1.  ;;    ___  Extension into joints
  1.  ;;    If checked, indicate joints affected:
  1.  ;;        Right: ___ Shoulder    ___ Elbow    ___ Wrist     ___ Hip    ___ Knee
  1.  ;;               ___ Ankle  ___ Multiple hand joints   ___ Multiple foot joints
  1.  ;;        Left:  ___ Shoulder    ___ Elbow    ___ Wrist     ___ Hip    ___ Knee
  1.  ;;              ___ Ankle  ___ Multiple hand joints   ___ Multiple foot joints
  1.  ;;        ___ Other, specify: _________________________________________________
  1.  ;;
  1.  ;; c. Dates of recurrent infection
  1.  ;; Indicate dates of recurrences:
  1.  ;;    Date of recurrence #1:________ Site of recurrent infection: _____________
  1.  ;;    Date of recurrence #2:________ Site of recurrent infection: _____________
  1.  ;;    Date of recurrence #3:________ Site of recurrent infection: _____________
  1.  ;;
  1.  ;;    If there are additional recurrences, list using above format: ___________
  1.  ;;
  1.  ;; 4. Signs, symptoms and findings
  1.  ;;
  1.  ;; a. Does the Veteran currently have any signs or findings attributable to
  1.  ;; osteomyelitis or treatment for osteomyelitis?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Involucrum
  1.  ;;    ___ Sequestrum
  1.  ;;    ___ Discharging sinus
  1.  ;;    ___ Amyloidosis secondary to chronic infection
  1.  ;;    ___ Anemia
  1.  ;;        If checked, provide CBC results in diagnostic testing section.
  1.  ;;    ___ Decreased joint function or range of motion due to osteomyelitis or
  1.  ;;        residuals of treatment
  1.  ;;        If checked, indicate affected joints and ALSO complete appropriate
  1.  ;;        Questionnaire for each affected joint and/or spinal segment.
  1.  ;;        Right: ___ Shoulder    ___ Elbow    ___ Wrist     ___ Hip    ___ Knee
  1.  ;;               ___ Ankle  ___ Multiple hand joints   ___ Multiple foot joints
  1.  ;;               ___ Single hand joint       ___ Single foot joint
  1.  ;;^TOF^
  1.  ;;        Left:  ___ Shoulder    ___ Elbow    ___ Wrist     ___ Hip    ___ Knee
  1.  ;;               ___ Ankle  ___ Multiple hand joints   ___ Multiple foot joints
  1.  ;;               ___ Single hand joint       ___ Single foot joint 
  1.  ;;        ___ Cervical vertebral joint(s)  ___ Thoracolumbar vertebral joint(s)
  1.  ;;            Specific vertebral joint(s) affected ____________________________
  1.  ;;
  1.  ;; b. Does the Veteran currently have any symptoms attributable to
  1.  ;; osteomyelitis or treatment for osteomyelitis?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Pain
  1.  ;;    If checked, describe: ___________________________________________________
  1.  ;;    ___ Swelling
  1.  ;;    If checked, describe: ___________________________________________________
  1.  ;;    ___ Tenderness
  1.  ;;    If checked, describe: ___________________________________________________
  1.  ;;    ___ Erythema
  1.  ;;    If checked, describe: ___________________________________________________
  1.  ;;    ___ Warmth
  1.  ;;    If checked, describe: ___________________________________________________
  1.  ;;    ___ Malaise
  1.  ;;    If checked, describe: ___________________________________________________
  1.  ;;    ___ Other symptoms, describe: ___________________________________________
  1.  ;;
  1.  ;; 5. Amputation
  1.  ;;
  1.  ;; Has the Veteran had an amputation due to osteomyelitis?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, complete Amputation Questionnaire.
  1.  ;;
  1.  ;; 6. Assistive devices
  1.  ;;
  1.  ;; a. Does the Veteran use any assistive devices as a normal mode of
  1.  ;; locomotion, although occasional locomotion by other methods may be possible?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, identify assistive device(s) used (check all that apply and indicate
  1.  ;; frequency):
  1.  ;;   __ Wheelchair  Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Brace(s)    Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Crutch(es)  Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Cane(s)     Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Walker      Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Other: ________________________________________________________________
  1.  ;;                  Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;
  1.  ;; b. If the Veteran uses any assistive devices, specify the condition and
  1.  ;; identify the assistive device used for each condition: _____________________
  1.  ;;^TOF^
  1.  ;; 7. Remaining effective function of the extremities
  1.  ;;
  1.  ;; Due to the Veteran's osteomyelitis or residuals of treatment, is there
  1.  ;; functional impairment of an extremity such that no effective function
  1.  ;; remains other than that which would be equally well served by an amputation
  1.  ;; with prosthesis? (Functions of the upper extremity include grasping,
  1.  ;; manipulation, etc., while functions for the lower extremity include balance
  1.  ;; and propulsion, etc.)
  1.  ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
  1.  ;; equally serve the Veteran.
  1.  ;; ___ No
  1.  ;; If yes, indicate extremities for which this applies:
  1.  ;;    ___ Right upper    ___ Left upper     ___ Right lower    ___ Left lower
  1.  ;;    For each checked extremity, identify the condition causing loss of
  1.  ;;    function, describe loss of effective function and provide specific
  1.  ;;    examples (brief summary): _______________________________________________
  1.  ;;
  1.  ;; 8. 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.  ;; 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 and/or symptoms related to any conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, describe (brief summary): __________________________________________
  1.  ;;
  1.  ;; 9. Diagnostic testing
  1.  ;;
  1.  ;; a. Have imaging or laboratory studies been performed and are the results
  1.  ;; available?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, indicate tests performed, dates and results:
  1.  ;;    ___ Bone scan         Date of test: ___________  Results: _______________
  1.  ;;    ___ X-ray             Date of test: ___________  Results: _______________
  1.  ;;    ___ MRI               Date of test: ___________  Results: _______________
  1.  ;;    ___ Complete blood count (CBC)
  1.  ;;                          Date of test: ___________  Results: _______________
  1.  ;;    ___ C-reactive protein (CRP)
  1.  ;;                          Date of test: ___________  Results: _______________
  1.  ;;^TOF^
  1.  ;;    ___ Erythrocyte sedimentation rate (ESR)
  1.  ;;                          Date of test: ___________  Results: _______________
  1.  ;;    ___ Blood culture     Date of test: ___________  Results: _______________
  1.  ;;    ___ Bone biopsy and culture
  1.  ;;                          Date of test: ___________  Results: _______________
  1.  ;;    ___ Other, describe: ________________
  1.  ;;                          Date of test: ___________  Results: _______________
  1.  ;;
  1.  ;; b. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, provide type of test or procedure, date and results (brief
  1.  ;; summary): __________________________________________________________________
  1.  ;;
  1.  ;; 10. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's osteomyelitis impact his or her ability to work?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes describe the impact of the Veteran's osteomyelitis or residuals of
  1.  ;; treatment, providing one or more examples: _________________________________
  1.  ;;
  1.  ;; 11. 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.  ;;^END^
  1.  Q