DVBCQPA2 ;;ALB-CIOFO/ECF,SBW - PERITONEAL ADHESIONS; 5/JUL/2011
;;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 a peritoneal
;; adhesion?
;; ___ Yes ___ No
;; If yes, provide only diagnoses that pertain to peritoneal adhesions:
;; Diagnosis #1: _______________________
;; ICD code: ___________________________
;; Date of diagnosis #1: _______________
;;
;; Diagnosis #2: _______________________
;; ICD code: ___________________________
;; Date of diagnosis #2: _______________
;;
;; Diagnosis #3: _______________________
;; ICD code: ___________________________
;; Date of diagnosis #3: _______________
;;
;; If there are additional diagnoses that pertain to peritoneal adhesions, list
;; using above format: ________________________________________________________
;;
;; 2. Medical history
;; a. Describe the history (including cause, onset and course) of the Veteran's
;; peritoneal adhesions (brief summary): _______________________________________
;; _____________________________________________________________________________
;;
;; b. Does the Veteran have a history of operative, traumatic or infectious
;; (intraabdominal) process?
;; ___ Yes ___ No
;; If yes, indicate organ(s) affected (check all that apply):
;; ___ Stomach ___ Gall bladder ___ Liver ___ Small intestine
;; ___ Large intestine other: _______________________________
;;
;; c. Has the Veteran had severe peritonitis, ruptured appendix, perforated
;; ulcer or operation with drainage?
;; ___ Yes ___ No
;;
;; d. Does the Veteran have a current diagnosis of peritoneal adhesions?
;; ___ Yes ___ No
;; If yes, indicate organ(s) affected (check all that apply):
;; ___ Stomach ___ Gall bladder ___ Liver ___ Small intestine
;; ___ Large intestine other: _______________________________
;;^TOF^
;; e. Does the Veteran have any signs and/or symptoms due to peritoneal adhesions?
;; ___ Yes ___ No
;; If yes, indicate signs and symptoms: (check all that apply)
;; ___ Delayed motility of barium meal (on X-ray)
;; ___ Partial or complete bowel obstruction
;; ___ Reflex disturbances
;; ___ Pain
;; ___ Nausea
;; ___ Vomiting
;; ___ Abdominal distention
;; ___ Constipation (perhaps alternating with diarrhea)
;;
;; f. Does the Veteran's treatment plan include taking continuous medication
;; for the diagnosed condition?
;; ___ Yes ___ No List medications: _____________________________________
;;
;; 3. Severity of manifestations of peritoneal adhesions
;; Indicate level of severity of signs and/or symptoms, if present:
;; (check all that apply in each level)
;;
;; a. Level IV
;; ___ Severe
;; ___ Definite partial obstruction shown by x-ray
;; ___ Frequent episodes of severe colic distension
;; ___ Frequent episodes of severe nausea
;; ___ Frequent episodes of severe vomiting
;; ___ Prolonged episodes of severe colic distension
;; ___ Prolonged episodes of severe nausea
;; ___ Prolonged episodes of severe vomiting
;; b. Level III
;; ___ Moderately severe
;; ___ Partial obstruction manifested by delayed motility of barium meal
;; ___ Less frequent episodes of pain
;; ___ Less prolonged episodes of pain
;;
;; c. Level II
;; ___ Moderate
;; ___ Pulling pain on attempting work or aggravated by movements of the body
;; ___ Occasional episodes of colic pain
;; ___ Occasional episodes of nausea
;; ___ Occasional episodes of constipation (perhaps alternating with diarrhea)
;; ___ Abdominal distension
;;
;; d. Level I
;; ___ Mild, describe: _________________________________________________________
;;^TOF^
;; 4. 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): ___________________________________________
;;
;; 5. Diagnostic testing
;; Has the Veteran had laboratory or other diagnostic studies performed and are
;; the results available?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; _____________________________________________________________________________
;;
;; 6. Functional impact
;; Based on your examination and/or the Veteran's history, does the Veteran's
;; peritoneal adhesion(s) impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's peritoneal adhesions,
;; providing one or more examples: _____________________________________________
;; _____________________________________________________________________________
;;
;; 7. Remarks, if any __________________________________________________________
;;
;; _____________________________________________________________________________
;;
;; Physician signature: _____________________________________ Date: ____________
;;
;; Physician printed name: __________________________________
;;
;; Medical license #: __________________
;;
;; Physician address: __________________________________________________________
;;
;; Phone: ____________________________ Fax: __________________________
;;
;; 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[HDVBCQPA2 6475 printed Dec 13, 2024@01:47:33 Page 2
DVBCQPA2 ;;ALB-CIOFO/ECF,SBW - PERITONEAL ADHESIONS; 5/JUL/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;;
+5 ;; 1. Diagnosis
+6 ;; Does the Veteran now have or has he/she ever been diagnosed with a peritoneal
+7 ;; adhesion?
+8 ;; ___ Yes ___ No
+9 ;; If yes, provide only diagnoses that pertain to peritoneal adhesions:
+10 ;; Diagnosis #1: _______________________
+11 ;; ICD code: ___________________________
+12 ;; Date of diagnosis #1: _______________
+13 ;;
+14 ;; Diagnosis #2: _______________________
+15 ;; ICD code: ___________________________
+16 ;; Date of diagnosis #2: _______________
+17 ;;
+18 ;; Diagnosis #3: _______________________
+19 ;; ICD code: ___________________________
+20 ;; Date of diagnosis #3: _______________
+21 ;;
+22 ;; If there are additional diagnoses that pertain to peritoneal adhesions, list
+23 ;; using above format: ________________________________________________________
+24 ;;
+25 ;; 2. Medical history
+26 ;; a. Describe the history (including cause, onset and course) of the Veteran's
+27 ;; peritoneal adhesions (brief summary): _______________________________________
+28 ;; _____________________________________________________________________________
+29 ;;
+30 ;; b. Does the Veteran have a history of operative, traumatic or infectious
+31 ;; (intraabdominal) process?
+32 ;; ___ Yes ___ No
+33 ;; If yes, indicate organ(s) affected (check all that apply):
+34 ;; ___ Stomach ___ Gall bladder ___ Liver ___ Small intestine
+35 ;; ___ Large intestine other: _______________________________
+36 ;;
+37 ;; c. Has the Veteran had severe peritonitis, ruptured appendix, perforated
+38 ;; ulcer or operation with drainage?
+39 ;; ___ Yes ___ No
+40 ;;
+41 ;; d. Does the Veteran have a current diagnosis of peritoneal adhesions?
+42 ;; ___ Yes ___ No
+43 ;; If yes, indicate organ(s) affected (check all that apply):
+44 ;; ___ Stomach ___ Gall bladder ___ Liver ___ Small intestine
+45 ;; ___ Large intestine other: _______________________________
+46 ;;^TOF^
+47 ;; e. Does the Veteran have any signs and/or symptoms due to peritoneal adhesions?
+48 ;; ___ Yes ___ No
+49 ;; If yes, indicate signs and symptoms: (check all that apply)
+50 ;; ___ Delayed motility of barium meal (on X-ray)
+51 ;; ___ Partial or complete bowel obstruction
+52 ;; ___ Reflex disturbances
+53 ;; ___ Pain
+54 ;; ___ Nausea
+55 ;; ___ Vomiting
+56 ;; ___ Abdominal distention
+57 ;; ___ Constipation (perhaps alternating with diarrhea)
+58 ;;
+59 ;; f. Does the Veteran's treatment plan include taking continuous medication
+60 ;; for the diagnosed condition?
+61 ;; ___ Yes ___ No List medications: _____________________________________
+62 ;;
+63 ;; 3. Severity of manifestations of peritoneal adhesions
+64 ;; Indicate level of severity of signs and/or symptoms, if present:
+65 ;; (check all that apply in each level)
+66 ;;
+67 ;; a. Level IV
+68 ;; ___ Severe
+69 ;; ___ Definite partial obstruction shown by x-ray
+70 ;; ___ Frequent episodes of severe colic distension
+71 ;; ___ Frequent episodes of severe nausea
+72 ;; ___ Frequent episodes of severe vomiting
+73 ;; ___ Prolonged episodes of severe colic distension
+74 ;; ___ Prolonged episodes of severe nausea
+75 ;; ___ Prolonged episodes of severe vomiting
+76 ;; b. Level III
+77 ;; ___ Moderately severe
+78 ;; ___ Partial obstruction manifested by delayed motility of barium meal
+79 ;; ___ Less frequent episodes of pain
+80 ;; ___ Less prolonged episodes of pain
+81 ;;
+82 ;; c. Level II
+83 ;; ___ Moderate
+84 ;; ___ Pulling pain on attempting work or aggravated by movements of the body
+85 ;; ___ Occasional episodes of colic pain
+86 ;; ___ Occasional episodes of nausea
+87 ;; ___ Occasional episodes of constipation (perhaps alternating with diarrhea)
+88 ;; ___ Abdominal distension
+89 ;;
+90 ;; d. Level I
+91 ;; ___ Mild, describe: _________________________________________________________
+92 ;;^TOF^
+93 ;; 4. Other pertinent physical findings, complications, conditions, signs
+94 ;; and/or symptoms
+95 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+96 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+97 ;; section above?
+98 ;; ___ Yes ___ No
+99 ;; If yes, are any of the scars painful and/or unstable, or is the total area of
+100 ;; all related scars greater than 39 square cm (6 square inches)?
+101 ;; ___ Yes ___ No
+102 ;; If yes, also complete a Scars Questionnaire.
+103 ;;
+104 ;; b. Does the Veteran have any other pertinent physical findings,
+105 ;; complications, conditions, signs and/or symptoms related to any conditions
+106 ;; listed in the Diagnosis section above?
+107 ;; ___ Yes ___ No
+108 ;; If yes, describe (brief summary): ___________________________________________
+109 ;;
+110 ;; 5. Diagnostic testing
+111 ;; Has the Veteran had laboratory or other diagnostic studies performed and are
+112 ;; the results available?
+113 ;; ___ Yes ___ No
+114 ;; If yes, provide type of test or procedure, date and results (brief summary):
+115 ;; _____________________________________________________________________________
+116 ;;
+117 ;; 6. Functional impact
+118 ;; Based on your examination and/or the Veteran's history, does the Veteran's
+119 ;; peritoneal adhesion(s) impact his or her ability to work?
+120 ;; ___ Yes ___ No
+121 ;; If yes, describe the impact of each of the Veteran's peritoneal adhesions,
+122 ;; providing one or more examples: _____________________________________________
+123 ;; _____________________________________________________________________________
+124 ;;
+125 ;; 7. Remarks, if any __________________________________________________________
+126 ;;
+127 ;; _____________________________________________________________________________
+128 ;;
+129 ;; Physician signature: _____________________________________ Date: ____________
+130 ;;
+131 ;; Physician printed name: __________________________________
+132 ;;
+133 ;; Medical license #: __________________
+134 ;;
+135 ;; Physician address: __________________________________________________________
+136 ;;
+137 ;; Phone: ____________________________ Fax: __________________________
+138 ;;
+139 ;; NOTE: VA may request additional medical information, including additional
+140 ;; examinations if necessary to complete VA's review of the Veteran's application.
+141 ;; ^END^
+142 QUIT
