DVBCQPC2 ;;ALB-CIOFO/ECF - PROSTATE CANCER QUESTIONNAIRE ; 9/20/2010
;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
;
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 ever been diagnosed with prostate
;; cancer?
;;
;; ___ Yes ___ No
;;
;; If no, provide rationale (e.g. Veteran has never had prostate cancer):
;;
;; _____________________________________________________________________________
;;
;; If yes, provide only diagnoses that pertain to prostate cancer.
;;
;; 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 prostate cancer, list using
;; above format: ____________________
;;
;; 2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's current
;; prostate cancer condition (brief summary): _______________________________
;;
;; __________________________________________________________________________
;;^TOF^
;; b. Indicate status of disease:
;; ___ Active
;; ___ Remission
;;
;; 3. Treatment
;;
;; Has the Veteran completed any treatment for prostate cancer or is the
;; Veteran currently undergoing any treatment for prostate cancer?
;;
;; ___ Yes ___ No; watchful waiting
;;
;; If yes, indicate treatment type(s) (check all that apply):
;;
;; ___ Treatment completed; currently in watchful waiting status
;;
;; ___ Surgery
;; ___ Prostatectomy
;; ___ Other surgical procedure (describe): _____________________________
;; Date of surgery: __________
;;
;; ___ Radiation therapy
;; Date of completion of treatment or anticipated date of completion:_______
;;
;; ___ Brachytherapy
;; Date of treatment: __________
;;
;; ___ Antineoplastic chemotherapy
;; Date of most recent treatment: ______________
;; Date of completion of treatment or anticipated date of completion: ______
;;
;; ___ Androgen Deprivation Therapy (Hormonal Therapy)
;; Date of most recent treatment: ______________
;; Date of completion of treatment or anticipated date of completion: ______
;;
;; ___ Other therapeutic procedure and/or treatment (describe): ________________
;; Date of procedure: __________
;; Date of completion of treatment or anticipated date of completion: ______
;;
;;^TOF^
;; 4. Residual conditions and/or complications
;;
;; a. Does the Veteran have any residual conditions and/or complications due to
;; prostate cancer or treatment for prostate cancer?
;; ___ Yes ___ No
;; If yes, complete the following sections:
;;
;; b. Does the Veteran have voiding dysfunction causing urine leakage?
;; ___ Yes ___ No
;; If yes, check one:
;; ___ Does not require/does not use absorbent material
;; ___ Requires absorbent material that is changed less than 2 times per
;; day
;; ___ Requires absorbent material that is changed 2 to 4 times per day
;; ___ Requires absorbent material that is changed more than 4 times per
;; day
;;
;; c. Does the Veteran have voiding dysfunction causing signs and/or symptoms of
;; urinary frequency?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Daytime voiding interval between 2 and 3 hours
;; ___ Daytime voiding interval between 1 and 2 hours
;; ___ Daytime voiding interval less than 1 hour
;; ___ Nighttime awakening to void 2 times
;; ___ Nighttime awakening to void 3 to 4 times
;; ___ Nighttime awakening to void 5 or more times
;;
;; d. Does the Veteran have voiding dysfunction causing findings, signs and/or
;; symptoms of obstructed voiding?
;; ___ Yes ___ No
;; If yes, check all signs and symptoms that apply:
;; ___ Hesitancy
;; If checked, is hesitancy marked?
;; ___ Yes ___ No
;; ___ Slow or weak stream
;; If checked, is stream markedly slow or weak?
;; ___ Yes ___ No
;; ___ Decreased force of stream
;; If checked, is force of stream markedly decreased?
;; ___ Yes ___ No
;; ___ Stricture disease requiring dilatation 1 to 2 times per year
;; ___ Stricture disease requiring periodic dilatation every 2 to 3
;; months
;; ___ Recurrent urinary tract infections secondary to obstruction
;; ___ Uroflowmetry peak flow rate less than 10 cc/sec
;; ___ Post void residuals greater than 150 cc
;; ___ Urinary retention requiring intermittent or continuous
;; catheterization
;;^TOF^
;; e. Does the Veteran have voiding dysfunction requiring the use of an
;; appliance?
;; ___ Yes ___ No
;; If yes, describe: ________________________________________________________
;;
;; f. Does the Veteran have a history of recurrent symptomatic urinary tract
;; infections?
;; ___ Yes ___ No
;;
;; If yes, check all treatments that apply:
;; ___ No treatment
;; ___ Long-term drug therapy
;; If checked, list medications used for urinary tract infection and
;; indicate dates for courses of treatment over the past 12 months:
;;
;; ______________________________________________________________________
;;
;; ___ Hospitalization
;; If checked, indicate frequency of hospitalization:
;; ___ 1 or 2 per year
;; ___ More than 2 per year
;;
;; ___ Drainage
;; If checked, indicate dates when drainage performed over past 12
;; months: ________________
;;
;; ___ Intensive management
;; If checked, indicate frequency of management:
;; ___ Continuous
;; ___ Intermittent
;;
;; g. Does the Veteran have erectile dysfunction?
;; ___ Yes ___ No
;;
;; If yes, is the erectile dysfunction as likely as not (at least a 50%
;; probability) attributable to prostate cancer, including treatment or
;; residuals of treatment for prostate cancer?
;; ___ Yes ___ No
;;
;; If no, provide the etiology of the erectile dysfunction: _____________
;; ______________________________________________________________________
;;
;; If yes, is the Veteran able to achieve an erection (without
;; medication) sufficient for penetration and ejaculation?
;; ___ Yes ___ No
;;
;; If no, is the Veteran able to achieve an erection (with medication)
;; sufficient for penetration and ejaculation?
;; ___ Yes ___ No
;;^TOF^
;; h. Does the Veteran have any other residual complications of prostate
;; cancer or treatment for prostate cancer?
;; ___ Yes ___ No
;;
;; If yes, describe: ________________________________________________________
;;
;; 5. Other pertinent physical findings, complications, conditions, signs and/or
;; symptoms
;;
;; Does the Veteran have any other pertinent physical findings, complications,
;; conditions, signs and/or symptoms?
;; ___ Yes ___ No
;;
;; If yes, describe: ___________________________________________________________
;;
;; 6. Diagnostic testing
;;
;; NOTE: If laboratory test results are in the medical record and reflect the
;; Veteran's current condition, repeat testing is not required.
;;
;; Are there any significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;;
;; If yes, provide type of test or procedure, date and results (brief summary):
;;
;; _____________________________________________________________________________
;;^TOF^
;; 7. Functional impact
;;
;; Does the Veteran's prostate cancer impact his ability to work?
;; ___ Yes ___ No
;;
;; If yes, describe the impact of the Veteran's prostate cancer, providing one
;; or more examples: ___________________________________________________________
;;
;; _____________________________________________________________________________
;;
;; 8. Remarks, if any __________________________________________________________
;;
;; Physician signature: _____________________________________ Date: ____________
;;
;; Physician printed name: __________________________________ Phone: ___________
;;
;; Medical license #: __________________
;;
;; 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[HDVBCQPC2 9409 printed Dec 13, 2024@01:47:35 Page 2
DVBCQPC2 ;;ALB-CIOFO/ECF - PROSTATE CANCER QUESTIONNAIRE ; 9/20/2010
+1 ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran now have or has he ever been diagnosed with prostate
+10 ;; cancer?
+11 ;;
+12 ;; ___ Yes ___ No
+13 ;;
+14 ;; If no, provide rationale (e.g. Veteran has never had prostate cancer):
+15 ;;
+16 ;; _____________________________________________________________________________
+17 ;;
+18 ;; If yes, provide only diagnoses that pertain to prostate cancer.
+19 ;;
+20 ;; Diagnosis #1: ____________________
+21 ;;
+22 ;; ICD code: ________________________
+23 ;;
+24 ;; Date of diagnosis: _______________
+25 ;;
+26 ;; Diagnosis #2: ____________________
+27 ;;
+28 ;; ICD code: ________________________
+29 ;;
+30 ;; Date of diagnosis: _______________
+31 ;;
+32 ;; Diagnosis #3: ____________________
+33 ;;
+34 ;; ICD code: ________________________
+35 ;;
+36 ;; Date of diagnosis: _______________
+37 ;;
+38 ;; If there are additional diagnoses that pertain to prostate cancer, list using
+39 ;; above format: ____________________
+40 ;;
+41 ;; 2. Medical history
+42 ;;
+43 ;; a. Describe the history (including onset and course) of the Veteran's current
+44 ;; prostate cancer condition (brief summary): _______________________________
+45 ;;
+46 ;; __________________________________________________________________________
+47 ;;^TOF^
+48 ;; b. Indicate status of disease:
+49 ;; ___ Active
+50 ;; ___ Remission
+51 ;;
+52 ;; 3. Treatment
+53 ;;
+54 ;; Has the Veteran completed any treatment for prostate cancer or is the
+55 ;; Veteran currently undergoing any treatment for prostate cancer?
+56 ;;
+57 ;; ___ Yes ___ No; watchful waiting
+58 ;;
+59 ;; If yes, indicate treatment type(s) (check all that apply):
+60 ;;
+61 ;; ___ Treatment completed; currently in watchful waiting status
+62 ;;
+63 ;; ___ Surgery
+64 ;; ___ Prostatectomy
+65 ;; ___ Other surgical procedure (describe): _____________________________
+66 ;; Date of surgery: __________
+67 ;;
+68 ;; ___ Radiation therapy
+69 ;; Date of completion of treatment or anticipated date of completion:_______
+70 ;;
+71 ;; ___ Brachytherapy
+72 ;; Date of treatment: __________
+73 ;;
+74 ;; ___ Antineoplastic chemotherapy
+75 ;; Date of most recent treatment: ______________
+76 ;; Date of completion of treatment or anticipated date of completion: ______
+77 ;;
+78 ;; ___ Androgen Deprivation Therapy (Hormonal Therapy)
+79 ;; Date of most recent treatment: ______________
+80 ;; Date of completion of treatment or anticipated date of completion: ______
+81 ;;
+82 ;; ___ Other therapeutic procedure and/or treatment (describe): ________________
+83 ;; Date of procedure: __________
+84 ;; Date of completion of treatment or anticipated date of completion: ______
+85 ;;
+86 ;;^TOF^
+87 ;; 4. Residual conditions and/or complications
+88 ;;
+89 ;; a. Does the Veteran have any residual conditions and/or complications due to
+90 ;; prostate cancer or treatment for prostate cancer?
+91 ;; ___ Yes ___ No
+92 ;; If yes, complete the following sections:
+93 ;;
+94 ;; b. Does the Veteran have voiding dysfunction causing urine leakage?
+95 ;; ___ Yes ___ No
+96 ;; If yes, check one:
+97 ;; ___ Does not require/does not use absorbent material
+98 ;; ___ Requires absorbent material that is changed less than 2 times per
+99 ;; day
+100 ;; ___ Requires absorbent material that is changed 2 to 4 times per day
+101 ;; ___ Requires absorbent material that is changed more than 4 times per
+102 ;; day
+103 ;;
+104 ;; c. Does the Veteran have voiding dysfunction causing signs and/or symptoms of
+105 ;; urinary frequency?
+106 ;; ___ Yes ___ No
+107 ;; If yes, check all that apply:
+108 ;; ___ Daytime voiding interval between 2 and 3 hours
+109 ;; ___ Daytime voiding interval between 1 and 2 hours
+110 ;; ___ Daytime voiding interval less than 1 hour
+111 ;; ___ Nighttime awakening to void 2 times
+112 ;; ___ Nighttime awakening to void 3 to 4 times
+113 ;; ___ Nighttime awakening to void 5 or more times
+114 ;;
+115 ;; d. Does the Veteran have voiding dysfunction causing findings, signs and/or
+116 ;; symptoms of obstructed voiding?
+117 ;; ___ Yes ___ No
+118 ;; If yes, check all signs and symptoms that apply:
+119 ;; ___ Hesitancy
+120 ;; If checked, is hesitancy marked?
+121 ;; ___ Yes ___ No
+122 ;; ___ Slow or weak stream
+123 ;; If checked, is stream markedly slow or weak?
+124 ;; ___ Yes ___ No
+125 ;; ___ Decreased force of stream
+126 ;; If checked, is force of stream markedly decreased?
+127 ;; ___ Yes ___ No
+128 ;; ___ Stricture disease requiring dilatation 1 to 2 times per year
+129 ;; ___ Stricture disease requiring periodic dilatation every 2 to 3
+130 ;; months
+131 ;; ___ Recurrent urinary tract infections secondary to obstruction
+132 ;; ___ Uroflowmetry peak flow rate less than 10 cc/sec
+133 ;; ___ Post void residuals greater than 150 cc
+134 ;; ___ Urinary retention requiring intermittent or continuous
+135 ;; catheterization
+136 ;;^TOF^
+137 ;; e. Does the Veteran have voiding dysfunction requiring the use of an
+138 ;; appliance?
+139 ;; ___ Yes ___ No
+140 ;; If yes, describe: ________________________________________________________
+141 ;;
+142 ;; f. Does the Veteran have a history of recurrent symptomatic urinary tract
+143 ;; infections?
+144 ;; ___ Yes ___ No
+145 ;;
+146 ;; If yes, check all treatments that apply:
+147 ;; ___ No treatment
+148 ;; ___ Long-term drug therapy
+149 ;; If checked, list medications used for urinary tract infection and
+150 ;; indicate dates for courses of treatment over the past 12 months:
+151 ;;
+152 ;; ______________________________________________________________________
+153 ;;
+154 ;; ___ Hospitalization
+155 ;; If checked, indicate frequency of hospitalization:
+156 ;; ___ 1 or 2 per year
+157 ;; ___ More than 2 per year
+158 ;;
+159 ;; ___ Drainage
+160 ;; If checked, indicate dates when drainage performed over past 12
+161 ;; months: ________________
+162 ;;
+163 ;; ___ Intensive management
+164 ;; If checked, indicate frequency of management:
+165 ;; ___ Continuous
+166 ;; ___ Intermittent
+167 ;;
+168 ;; g. Does the Veteran have erectile dysfunction?
+169 ;; ___ Yes ___ No
+170 ;;
+171 ;; If yes, is the erectile dysfunction as likely as not (at least a 50%
+172 ;; probability) attributable to prostate cancer, including treatment or
+173 ;; residuals of treatment for prostate cancer?
+174 ;; ___ Yes ___ No
+175 ;;
+176 ;; If no, provide the etiology of the erectile dysfunction: _____________
+177 ;; ______________________________________________________________________
+178 ;;
+179 ;; If yes, is the Veteran able to achieve an erection (without
+180 ;; medication) sufficient for penetration and ejaculation?
+181 ;; ___ Yes ___ No
+182 ;;
+183 ;; If no, is the Veteran able to achieve an erection (with medication)
+184 ;; sufficient for penetration and ejaculation?
+185 ;; ___ Yes ___ No
+186 ;;^TOF^
+187 ;; h. Does the Veteran have any other residual complications of prostate
+188 ;; cancer or treatment for prostate cancer?
+189 ;; ___ Yes ___ No
+190 ;;
+191 ;; If yes, describe: ________________________________________________________
+192 ;;
+193 ;; 5. Other pertinent physical findings, complications, conditions, signs and/or
+194 ;; symptoms
+195 ;;
+196 ;; Does the Veteran have any other pertinent physical findings, complications,
+197 ;; conditions, signs and/or symptoms?
+198 ;; ___ Yes ___ No
+199 ;;
+200 ;; If yes, describe: ___________________________________________________________
+201 ;;
+202 ;; 6. Diagnostic testing
+203 ;;
+204 ;; NOTE: If laboratory test results are in the medical record and reflect the
+205 ;; Veteran's current condition, repeat testing is not required.
+206 ;;
+207 ;; Are there any significant diagnostic test findings and/or results?
+208 ;; ___ Yes ___ No
+209 ;;
+210 ;; If yes, provide type of test or procedure, date and results (brief summary):
+211 ;;
+212 ;; _____________________________________________________________________________
+213 ;;^TOF^
+214 ;; 7. Functional impact
+215 ;;
+216 ;; Does the Veteran's prostate cancer impact his ability to work?
+217 ;; ___ Yes ___ No
+218 ;;
+219 ;; If yes, describe the impact of the Veteran's prostate cancer, providing one
+220 ;; or more examples: ___________________________________________________________
+221 ;;
+222 ;; _____________________________________________________________________________
+223 ;;
+224 ;; 8. Remarks, if any __________________________________________________________
+225 ;;
+226 ;; Physician signature: _____________________________________ Date: ____________
+227 ;;
+228 ;; Physician printed name: __________________________________ Phone: ___________
+229 ;;
+230 ;; Medical license #: __________________
+231 ;;
+232 ;; Physician address: __________________________________________________________
+233 ;;
+234 ;; NOTE: VA may request additional medical information, including additional
+235 ;; examinations if necessary to complete VA's review of the Veteran's
+236 ;; application.
+237 ;; ^END^
+238 QUIT
