- 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 Feb 18, 2025@23:14 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