DVBCQOS2 ;;ALB-CIOFO/ECF - OSTEOMYELITIS QUESTIONNAIRE ; 6/20/2010
;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
;
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/she ever been diagnosed with
;; osteomyelitis?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to osteomyelitis:
;; Diagnosis #1: ____________________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; Diagnosis #2: ____________________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; Diagnosis #3: ____________________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; If there are additional diagnoses that pertain to osteomyelitis, list using
;; above format: ______________________________________________________________
;;
;; 2. Medical History
;;
;; a. Describe the history (including onset and course) of the Veteran's
;; osteomyelitis (brief summary): _____________________________________________
;;
;; b. Indicate location of initial infection (check all that apply):
;; ___ Pelvis
;; ___ Cervical vertebrae
;; ___ Thoracolumbar vertebrae
;; ___ Long bones of upper extremity
;; Side affected: ___ Right ___ Left
;; ___ Long bones of lower extremity
;; Side affected: ___ Right ___ Left
;; ___ Finger(s): ___ Right, digit(s) affected _____________________________
;; ___ Left, digit(s) affected ______________________________
;; ___ Toe(s): ___ Right, digit(s) affected _____________________________
;; ___ Left, digit(s) affected ______________________________
;; ___ Other, specify: _____________________________________________________
;;^TOF^
;; ___ Extension into joints
;; If checked, indicate joints affected:
;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hip ___ Knee
;; ___ Ankle ___ Multiple hand joints ___ Multiple foot joints
;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hip ___ Knee
;; ___ Ankle ___ Multiple hand joints ___ Multiple foot joints
;; ___ Other, specify: _________________________________________________
;;
;; c. Has the Veteran had medical treatment or is the Veteran currently
;; undergoing medical treatment for osteomyelitis?
;; ___ Yes ___ No
;; If yes, describe treatment:______________________________________________
;; Date treatment started: _________________________________________________
;; Date treatment completed or anticipated date of completion: ________________
;;
;; d. Has the Veteran had surgical treatment for osteomyelitis?
;; ___ Yes ___ No
;; If yes, indicate surgical procedure and date (if multiple procedures,
;; indicate below):
;; Procedure #1: ____________________________________________________________
;; Date: ____________________________________________________________________
;; Facility: ________________________________________________________________
;;
;; Procedure #2: ____________________________________________________________
;; Date: ___________________
;; Facility: ________________________________________________________________
;;
;; If additional surgical procedures, list, using above format: _____________
;;
;; e. Provide status of the Veteran's current osteomyelitis condition:
;; ___ Acute ___ Subacute ___ Chronic ___ Inactive ___ Resolved
;; ___ Other: describe: _______________________________________________________
;;
;; 3. Recurrent infections
;;
;; a. Has the Veteran had any additional episodes or recurring infections of
;; osteomyelitis following the initial infection?
;; ___ Yes ___ No
;; If yes, indicate number of additional episodes:
;; ___ 1 ___ 2 ___ 3 ___ 4 ___ 5 or more
;;^TOF^
;; b. Location of recurrent infections (check all that apply):
;; ___ Pelvis
;; ___ Cervical vertebrae
;; ___ Thoracolumbar vertebrae
;; ___ Long bones of upper extremity
;; Side affected: ___ Right ___ Left
;; ___ Long bones of lower extremity
;; Side affected: ___ Right ___ Left
;; ___ Finger(s): ___ Right, digit(s) affected ___________________________
;; ___ Left, digit(s) affected ____________________________
;; ___ Toe(s): ___ Right, digit(s) affected ___________________________
;; ___ Left, digit(s) affected ____________________________
;; ___ Other, specify: _____________________________________________________
;;
;; ___ Extension into joints
;; If checked, indicate joints affected:
;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hip ___ Knee
;; ___ Ankle ___ Multiple hand joints ___ Multiple foot joints
;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hip ___ Knee
;; ___ Ankle ___ Multiple hand joints ___ Multiple foot joints
;; ___ Other, specify: _________________________________________________
;;
;; c. Dates of recurrent infection
;; Indicate dates of recurrences:
;; Date of recurrence #1:________ Site of recurrent infection: _____________
;; Date of recurrence #2:________ Site of recurrent infection: _____________
;; Date of recurrence #3:________ Site of recurrent infection: _____________
;;
;; If there are additional recurrences, list using above format: ___________
;;
;; 4. Signs, symptoms and findings
;;
;; a. Does the Veteran currently have any signs or findings attributable to
;; osteomyelitis or treatment for osteomyelitis?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Involucrum
;; ___ Sequestrum
;; ___ Discharging sinus
;; ___ Amyloidosis secondary to chronic infection
;; ___ Anemia
;; If checked, provide CBC results in diagnostic testing section.
;; ___ Decreased joint function or range of motion due to osteomyelitis or
;; residuals of treatment
;; If checked, indicate affected joints and ALSO complete appropriate
;; Questionnaire for each affected joint and/or spinal segment.
;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hip ___ Knee
;; ___ Ankle ___ Multiple hand joints ___ Multiple foot joints
;; ___ Single hand joint ___ Single foot joint
;;^TOF^
;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hip ___ Knee
;; ___ Ankle ___ Multiple hand joints ___ Multiple foot joints
;; ___ Single hand joint ___ Single foot joint
;; ___ Cervical vertebral joint(s) ___ Thoracolumbar vertebral joint(s)
;; Specific vertebral joint(s) affected ____________________________
;;
;; b. Does the Veteran currently have any symptoms attributable to
;; osteomyelitis or treatment for osteomyelitis?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Pain
;; If checked, describe: ___________________________________________________
;; ___ Swelling
;; If checked, describe: ___________________________________________________
;; ___ Tenderness
;; If checked, describe: ___________________________________________________
;; ___ Erythema
;; If checked, describe: ___________________________________________________
;; ___ Warmth
;; If checked, describe: ___________________________________________________
;; ___ Malaise
;; If checked, describe: ___________________________________________________
;; ___ Other symptoms, describe: ___________________________________________
;;
;; 5. Amputation
;;
;; Has the Veteran had an amputation due to osteomyelitis?
;; ___ Yes ___ No
;; If yes, complete Amputation Questionnaire.
;;
;; 6. Assistive devices
;;
;; a. Does the Veteran use any assistive devices as a normal mode of
;; locomotion, although occasional locomotion by other methods may be possible?
;; ___ Yes ___ No
;; If yes, identify assistive device(s) used (check all that apply and indicate
;; frequency):
;; __ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
;; __ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
;; __ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
;; __ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
;; __ Walker Frequency of use: __ Occasional __ Regular __ Constant
;; __ Other: ________________________________________________________________
;; Frequency of use: __ Occasional __ Regular __ Constant
;;
;; b. If the Veteran uses any assistive devices, specify the condition and
;; identify the assistive device used for each condition: _____________________
;;^TOF^
;; 7. Remaining effective function of the extremities
;;
;; Due to the Veteran's osteomyelitis or residuals of treatment, is there
;; functional impairment of an extremity such that no effective function
;; remains other than that which would be equally well served by an amputation
;; with prosthesis? (Functions of the upper extremity include grasping,
;; manipulation, etc., while functions for the lower extremity include balance
;; and propulsion, etc.)
;; ___ Yes, functioning is so diminished that amputation with prosthesis would
;; equally serve the Veteran.
;; ___ No
;; If yes, indicate extremities for which this applies:
;; ___ Right upper ___ Left upper ___ Right lower ___ Left lower
;; For each checked extremity, identify the condition causing loss of
;; function, describe loss of effective function and provide specific
;; examples (brief summary): _______________________________________________
;;
;; 8. 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 and/or symptoms related to any conditions
;; listed in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): __________________________________________
;;
;; 9. Diagnostic testing
;;
;; a. Have imaging or laboratory studies been performed and are the results
;; available?
;; ___ Yes ___ No
;; If yes, indicate tests performed, dates and results:
;; ___ Bone scan Date of test: ___________ Results: _______________
;; ___ X-ray Date of test: ___________ Results: _______________
;; ___ MRI Date of test: ___________ Results: _______________
;; ___ Complete blood count (CBC)
;; Date of test: ___________ Results: _______________
;; ___ C-reactive protein (CRP)
;; Date of test: ___________ Results: _______________
;;^TOF^
;; ___ Erythrocyte sedimentation rate (ESR)
;; Date of test: ___________ Results: _______________
;; ___ Blood culture Date of test: ___________ Results: _______________
;; ___ Bone biopsy and culture
;; Date of test: ___________ Results: _______________
;; ___ Other, describe: ________________
;; Date of test: ___________ Results: _______________
;;
;; b. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief
;; summary): __________________________________________________________________
;;
;; 10. Functional impact
;;
;; Does the Veteran's osteomyelitis impact his or her ability to work?
;; ___ Yes ___ No
;; If yes describe the impact of the Veteran's osteomyelitis or residuals of
;; treatment, providing one or more examples: _________________________________
;;
;; 11. 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[HDVBCQOS2 13479 printed Nov 22, 2024@16:57:43 Page 2
DVBCQOS2 ;;ALB-CIOFO/ECF - OSTEOMYELITIS QUESTIONNAIRE ; 6/20/2010
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA)
+3 ;; for disability benefits. VA will consider the information you provide on
+4 ;; this questionnaire as part of their evaluation in processing the Veteran's
+5 ;; claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;; Does the Veteran now have or has he/she ever been diagnosed with
+9 ;; osteomyelitis?
+10 ;; ___ Yes ___ No
+11 ;;
+12 ;; If yes, provide only diagnoses that pertain to osteomyelitis:
+13 ;; Diagnosis #1: ____________________
+14 ;; ICD code: ________________________
+15 ;; Date of diagnosis: _______________
+16 ;;
+17 ;; Diagnosis #2: ____________________
+18 ;; ICD code: ________________________
+19 ;; Date of diagnosis: _______________
+20 ;;
+21 ;; Diagnosis #3: ____________________
+22 ;; ICD code: ________________________
+23 ;; Date of diagnosis: _______________
+24 ;;
+25 ;; If there are additional diagnoses that pertain to osteomyelitis, list using
+26 ;; above format: ______________________________________________________________
+27 ;;
+28 ;; 2. Medical History
+29 ;;
+30 ;; a. Describe the history (including onset and course) of the Veteran's
+31 ;; osteomyelitis (brief summary): _____________________________________________
+32 ;;
+33 ;; b. Indicate location of initial infection (check all that apply):
+34 ;; ___ Pelvis
+35 ;; ___ Cervical vertebrae
+36 ;; ___ Thoracolumbar vertebrae
+37 ;; ___ Long bones of upper extremity
+38 ;; Side affected: ___ Right ___ Left
+39 ;; ___ Long bones of lower extremity
+40 ;; Side affected: ___ Right ___ Left
+41 ;; ___ Finger(s): ___ Right, digit(s) affected _____________________________
+42 ;; ___ Left, digit(s) affected ______________________________
+43 ;; ___ Toe(s): ___ Right, digit(s) affected _____________________________
+44 ;; ___ Left, digit(s) affected ______________________________
+45 ;; ___ Other, specify: _____________________________________________________
+46 ;;^TOF^
+47 ;; ___ Extension into joints
+48 ;; If checked, indicate joints affected:
+49 ;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hip ___ Knee
+50 ;; ___ Ankle ___ Multiple hand joints ___ Multiple foot joints
+51 ;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hip ___ Knee
+52 ;; ___ Ankle ___ Multiple hand joints ___ Multiple foot joints
+53 ;; ___ Other, specify: _________________________________________________
+54 ;;
+55 ;; c. Has the Veteran had medical treatment or is the Veteran currently
+56 ;; undergoing medical treatment for osteomyelitis?
+57 ;; ___ Yes ___ No
+58 ;; If yes, describe treatment:______________________________________________
+59 ;; Date treatment started: _________________________________________________
+60 ;; Date treatment completed or anticipated date of completion: ________________
+61 ;;
+62 ;; d. Has the Veteran had surgical treatment for osteomyelitis?
+63 ;; ___ Yes ___ No
+64 ;; If yes, indicate surgical procedure and date (if multiple procedures,
+65 ;; indicate below):
+66 ;; Procedure #1: ____________________________________________________________
+67 ;; Date: ____________________________________________________________________
+68 ;; Facility: ________________________________________________________________
+69 ;;
+70 ;; Procedure #2: ____________________________________________________________
+71 ;; Date: ___________________
+72 ;; Facility: ________________________________________________________________
+73 ;;
+74 ;; If additional surgical procedures, list, using above format: _____________
+75 ;;
+76 ;; e. Provide status of the Veteran's current osteomyelitis condition:
+77 ;; ___ Acute ___ Subacute ___ Chronic ___ Inactive ___ Resolved
+78 ;; ___ Other: describe: _______________________________________________________
+79 ;;
+80 ;; 3. Recurrent infections
+81 ;;
+82 ;; a. Has the Veteran had any additional episodes or recurring infections of
+83 ;; osteomyelitis following the initial infection?
+84 ;; ___ Yes ___ No
+85 ;; If yes, indicate number of additional episodes:
+86 ;; ___ 1 ___ 2 ___ 3 ___ 4 ___ 5 or more
+87 ;;^TOF^
+88 ;; b. Location of recurrent infections (check all that apply):
+89 ;; ___ Pelvis
+90 ;; ___ Cervical vertebrae
+91 ;; ___ Thoracolumbar vertebrae
+92 ;; ___ Long bones of upper extremity
+93 ;; Side affected: ___ Right ___ Left
+94 ;; ___ Long bones of lower extremity
+95 ;; Side affected: ___ Right ___ Left
+96 ;; ___ Finger(s): ___ Right, digit(s) affected ___________________________
+97 ;; ___ Left, digit(s) affected ____________________________
+98 ;; ___ Toe(s): ___ Right, digit(s) affected ___________________________
+99 ;; ___ Left, digit(s) affected ____________________________
+100 ;; ___ Other, specify: _____________________________________________________
+101 ;;
+102 ;; ___ Extension into joints
+103 ;; If checked, indicate joints affected:
+104 ;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hip ___ Knee
+105 ;; ___ Ankle ___ Multiple hand joints ___ Multiple foot joints
+106 ;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hip ___ Knee
+107 ;; ___ Ankle ___ Multiple hand joints ___ Multiple foot joints
+108 ;; ___ Other, specify: _________________________________________________
+109 ;;
+110 ;; c. Dates of recurrent infection
+111 ;; Indicate dates of recurrences:
+112 ;; Date of recurrence #1:________ Site of recurrent infection: _____________
+113 ;; Date of recurrence #2:________ Site of recurrent infection: _____________
+114 ;; Date of recurrence #3:________ Site of recurrent infection: _____________
+115 ;;
+116 ;; If there are additional recurrences, list using above format: ___________
+117 ;;
+118 ;; 4. Signs, symptoms and findings
+119 ;;
+120 ;; a. Does the Veteran currently have any signs or findings attributable to
+121 ;; osteomyelitis or treatment for osteomyelitis?
+122 ;; ___ Yes ___ No
+123 ;; If yes, check all that apply:
+124 ;; ___ Involucrum
+125 ;; ___ Sequestrum
+126 ;; ___ Discharging sinus
+127 ;; ___ Amyloidosis secondary to chronic infection
+128 ;; ___ Anemia
+129 ;; If checked, provide CBC results in diagnostic testing section.
+130 ;; ___ Decreased joint function or range of motion due to osteomyelitis or
+131 ;; residuals of treatment
+132 ;; If checked, indicate affected joints and ALSO complete appropriate
+133 ;; Questionnaire for each affected joint and/or spinal segment.
+134 ;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hip ___ Knee
+135 ;; ___ Ankle ___ Multiple hand joints ___ Multiple foot joints
+136 ;; ___ Single hand joint ___ Single foot joint
+137 ;;^TOF^
+138 ;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hip ___ Knee
+139 ;; ___ Ankle ___ Multiple hand joints ___ Multiple foot joints
+140 ;; ___ Single hand joint ___ Single foot joint
+141 ;; ___ Cervical vertebral joint(s) ___ Thoracolumbar vertebral joint(s)
+142 ;; Specific vertebral joint(s) affected ____________________________
+143 ;;
+144 ;; b. Does the Veteran currently have any symptoms attributable to
+145 ;; osteomyelitis or treatment for osteomyelitis?
+146 ;; ___ Yes ___ No
+147 ;; If yes, check all that apply:
+148 ;; ___ Pain
+149 ;; If checked, describe: ___________________________________________________
+150 ;; ___ Swelling
+151 ;; If checked, describe: ___________________________________________________
+152 ;; ___ Tenderness
+153 ;; If checked, describe: ___________________________________________________
+154 ;; ___ Erythema
+155 ;; If checked, describe: ___________________________________________________
+156 ;; ___ Warmth
+157 ;; If checked, describe: ___________________________________________________
+158 ;; ___ Malaise
+159 ;; If checked, describe: ___________________________________________________
+160 ;; ___ Other symptoms, describe: ___________________________________________
+161 ;;
+162 ;; 5. Amputation
+163 ;;
+164 ;; Has the Veteran had an amputation due to osteomyelitis?
+165 ;; ___ Yes ___ No
+166 ;; If yes, complete Amputation Questionnaire.
+167 ;;
+168 ;; 6. Assistive devices
+169 ;;
+170 ;; a. Does the Veteran use any assistive devices as a normal mode of
+171 ;; locomotion, although occasional locomotion by other methods may be possible?
+172 ;; ___ Yes ___ No
+173 ;; If yes, identify assistive device(s) used (check all that apply and indicate
+174 ;; frequency):
+175 ;; __ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
+176 ;; __ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
+177 ;; __ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
+178 ;; __ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
+179 ;; __ Walker Frequency of use: __ Occasional __ Regular __ Constant
+180 ;; __ Other: ________________________________________________________________
+181 ;; Frequency of use: __ Occasional __ Regular __ Constant
+182 ;;
+183 ;; b. If the Veteran uses any assistive devices, specify the condition and
+184 ;; identify the assistive device used for each condition: _____________________
+185 ;;^TOF^
+186 ;; 7. Remaining effective function of the extremities
+187 ;;
+188 ;; Due to the Veteran's osteomyelitis or residuals of treatment, is there
+189 ;; functional impairment of an extremity such that no effective function
+190 ;; remains other than that which would be equally well served by an amputation
+191 ;; with prosthesis? (Functions of the upper extremity include grasping,
+192 ;; manipulation, etc., while functions for the lower extremity include balance
+193 ;; and propulsion, etc.)
+194 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+195 ;; equally serve the Veteran.
+196 ;; ___ No
+197 ;; If yes, indicate extremities for which this applies:
+198 ;; ___ Right upper ___ Left upper ___ Right lower ___ Left lower
+199 ;; For each checked extremity, identify the condition causing loss of
+200 ;; function, describe loss of effective function and provide specific
+201 ;; examples (brief summary): _______________________________________________
+202 ;;
+203 ;; 8. Other pertinent physical findings, complications, conditions, signs
+204 ;; and/or symptoms
+205 ;;
+206 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+207 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+208 ;; section above?
+209 ;; ___ Yes ___ No
+210 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+211 ;; of all related scars greater than 39 square cm (6 square inches)?
+212 ;; ___ Yes ___ No
+213 ;; If yes, also complete a Scars Questionnaire.
+214 ;;
+215 ;; b. Does the Veteran have any other pertinent physical findings,
+216 ;; complications, conditions, signs and/or symptoms related to any conditions
+217 ;; listed in the Diagnosis section above?
+218 ;; ___ Yes ___ No
+219 ;; If yes, describe (brief summary): __________________________________________
+220 ;;
+221 ;; 9. Diagnostic testing
+222 ;;
+223 ;; a. Have imaging or laboratory studies been performed and are the results
+224 ;; available?
+225 ;; ___ Yes ___ No
+226 ;; If yes, indicate tests performed, dates and results:
+227 ;; ___ Bone scan Date of test: ___________ Results: _______________
+228 ;; ___ X-ray Date of test: ___________ Results: _______________
+229 ;; ___ MRI Date of test: ___________ Results: _______________
+230 ;; ___ Complete blood count (CBC)
+231 ;; Date of test: ___________ Results: _______________
+232 ;; ___ C-reactive protein (CRP)
+233 ;; Date of test: ___________ Results: _______________
+234 ;;^TOF^
+235 ;; ___ Erythrocyte sedimentation rate (ESR)
+236 ;; Date of test: ___________ Results: _______________
+237 ;; ___ Blood culture Date of test: ___________ Results: _______________
+238 ;; ___ Bone biopsy and culture
+239 ;; Date of test: ___________ Results: _______________
+240 ;; ___ Other, describe: ________________
+241 ;; Date of test: ___________ Results: _______________
+242 ;;
+243 ;; b. Are there any other significant diagnostic test findings and/or results?
+244 ;; ___ Yes ___ No
+245 ;; If yes, provide type of test or procedure, date and results (brief
+246 ;; summary): __________________________________________________________________
+247 ;;
+248 ;; 10. Functional impact
+249 ;;
+250 ;; Does the Veteran's osteomyelitis impact his or her ability to work?
+251 ;; ___ Yes ___ No
+252 ;; If yes describe the impact of the Veteran's osteomyelitis or residuals of
+253 ;; treatment, providing one or more examples: _________________________________
+254 ;;
+255 ;; 11. Remarks, if any:________________________________________________________
+256 ;;
+257 ;; Physician signature: ____________________________________ Date: ____________
+258 ;;
+259 ;; Physician printed name: _________________________________ Phone: ___________
+260 ;;
+261 ;; Medical license #: ______________________________________ FAX: _____________
+262 ;;
+263 ;; Physician address: _________________________________________________________
+264 ;;
+265 ;; NOTE: VA may request additional medical information, including additional
+266 ;; examinations if necessary to complete VA's review of the Veteran's
+267 ;; application.
+268 ;;^END^
+269 QUIT
