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Routine: DVBCQPA2

DVBCQPA2.m

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  1. DVBCQPA2 ;;ALB-CIOFO/ECF,SBW - PERITONEAL ADHESIONS; 5/JUL/2011
  1.  ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1.  ;; disability benefits.  VA will consider the information you provide on this
  1.  ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with a peritoneal
  1.  ;; adhesion?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide only diagnoses that pertain to peritoneal adhesions:
  1.  ;; Diagnosis #1: _______________________
  1.  ;; ICD code: ___________________________
  1.  ;; Date of diagnosis #1: _______________
  1.  ;;
  1.  ;; Diagnosis #2: _______________________
  1.  ;; ICD code: ___________________________
  1.  ;; Date of diagnosis #2: _______________
  1.  ;;
  1.  ;; Diagnosis #3: _______________________
  1.  ;; ICD code: ___________________________
  1.  ;; Date of diagnosis #3: _______________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to peritoneal adhesions, list
  1.  ;; using above format: ________________________________________________________
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;; a. Describe the history (including cause, onset and course) of the Veteran's
  1.  ;; peritoneal adhesions (brief summary): _______________________________________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; b. Does the Veteran have a history of operative, traumatic or infectious
  1.  ;; (intraabdominal) process?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate organ(s) affected (check all that apply):
  1.  ;;    ___ Stomach   ___ Gall bladder   ___ Liver   ___ Small intestine
  1.  ;;    ___ Large intestine   other: _______________________________
  1.  ;;
  1.  ;; c. Has the Veteran had severe peritonitis, ruptured appendix, perforated
  1.  ;; ulcer or operation with drainage?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; d. Does the Veteran have a current diagnosis of peritoneal adhesions?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate organ(s) affected (check all that apply):
  1.  ;;    ___ Stomach   ___ Gall bladder   ___ Liver   ___ Small intestine
  1.  ;;    ___ Large intestine   other: _______________________________
  1.  ;;^TOF^
  1.  ;; e. Does the Veteran have any signs and/or symptoms due to peritoneal adhesions? 
  1.  ;; ___ Yes   ___  No
  1.  ;; If yes, indicate signs and symptoms: (check all that apply)
  1.  ;;    ___ Delayed motility of barium meal (on X-ray)
  1.  ;;    ___ Partial or complete bowel obstruction
  1.  ;;    ___ Reflex disturbances
  1.  ;;    ___ Pain
  1.  ;;    ___ Nausea
  1.  ;;    ___ Vomiting
  1.  ;;    ___ Abdominal distention
  1.  ;;    ___ Constipation (perhaps alternating with diarrhea)
  1.  ;;
  1.  ;; f.  Does the Veteran's treatment plan include taking continuous medication
  1.  ;; for the diagnosed condition?
  1.  ;; ___ Yes   ___ No    List medications:  _____________________________________
  1.  ;;
  1.  ;; 3. Severity of manifestations of peritoneal adhesions
  1.  ;; Indicate level of severity of signs and/or symptoms, if present:
  1.  ;; (check all that apply in each level)
  1.  ;;
  1.  ;; a. Level IV
  1.  ;;    ___ Severe
  1.  ;;    ___ Definite partial obstruction shown by x-ray
  1.  ;;    ___ Frequent episodes of severe colic distension
  1.  ;;    ___ Frequent episodes of severe nausea
  1.  ;;    ___ Frequent episodes of severe vomiting
  1.  ;;    ___ Prolonged episodes of severe colic distension
  1.  ;;    ___ Prolonged episodes of severe nausea
  1.  ;;    ___ Prolonged episodes of severe vomiting
  1.  ;; b. Level III
  1.  ;;    ___ Moderately severe
  1.  ;;    ___ Partial obstruction manifested by delayed motility of barium meal
  1.  ;;    ___ Less frequent episodes of pain
  1.  ;;    ___ Less prolonged episodes of pain
  1.  ;;
  1.  ;; c. Level II
  1.  ;; ___ Moderate
  1.  ;; ___ Pulling pain on attempting work or aggravated by movements of the body
  1.  ;; ___ Occasional episodes of colic pain
  1.  ;; ___ Occasional episodes of nausea
  1.  ;; ___ Occasional episodes of constipation (perhaps alternating with diarrhea)
  1.  ;; ___ Abdominal distension
  1.  ;;
  1.  ;; d. Level I
  1.  ;; ___ Mild, describe: _________________________________________________________
  1.  ;;^TOF^
  1.  ;; 4. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  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 of
  1.  ;; 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.  ;; 5. Diagnostic testing
  1.  ;; Has the Veteran had laboratory or other diagnostic studies performed and are
  1.  ;; the results available?
  1.  ;; ___ Yes   ___  No
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 6. Functional impact
  1.  ;; Based on your examination and/or the Veteran's history, does the Veteran's
  1.  ;; peritoneal adhesion(s) impact his or her ability to work? 
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe the impact of each of the Veteran's peritoneal adhesions,
  1.  ;; providing one or more examples: _____________________________________________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 7. Remarks, if any __________________________________________________________
  1.  ;;
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; Physician signature: _____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: __________________________________
  1.  ;;
  1.  ;; Medical license #: __________________                     
  1.  ;;
  1.  ;; Physician address: __________________________________________________________
  1.  ;; 
  1.  ;; Phone: ____________________________   Fax: __________________________
  1.  ;;
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's application.
  1.  ;; ^END^
  1.  Q