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Routine: DVBCQPC2

DVBCQPC2.m

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  1. DVBCQPC2 ;;ALB-CIOFO/ECF - PROSTATE CANCER QUESTIONNAIRE ; 9/20/2010
  1. ;;2.7;AMIE;**161**;Apr 10, 1995;Build 8
  1. ;
  1. TXT ;
  1. ;;
  1. ;; Your patient is applying to the U. S. Department of Veterans Affairs
  1. ;; (VA) for disability benefits. VA will consider the information you
  1. ;; provide on this questionnaire as part of their evaluation in processing
  1. ;; the Veteran's claim.
  1. ;;
  1. ;; 1. Diagnosis
  1. ;;
  1. ;; Does the Veteran now have or has he ever been diagnosed with prostate
  1. ;; cancer?
  1. ;;
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, provide rationale (e.g. Veteran has never had prostate cancer):
  1. ;;
  1. ;; _____________________________________________________________________________
  1. ;;
  1. ;; If yes, provide only diagnoses that pertain to prostate cancer.
  1. ;;
  1. ;; Diagnosis #1: ____________________
  1. ;;
  1. ;; ICD code: ________________________
  1. ;;
  1. ;; Date of diagnosis: _______________
  1. ;;
  1. ;; Diagnosis #2: ____________________
  1. ;;
  1. ;; ICD code: ________________________
  1. ;;
  1. ;; Date of diagnosis: _______________
  1. ;;
  1. ;; Diagnosis #3: ____________________
  1. ;;
  1. ;; ICD code: ________________________
  1. ;;
  1. ;; Date of diagnosis: _______________
  1. ;;
  1. ;; If there are additional diagnoses that pertain to prostate cancer, list using
  1. ;; above format: ____________________
  1. ;;
  1. ;; 2. Medical history
  1. ;;
  1. ;; a. Describe the history (including onset and course) of the Veteran's current
  1. ;; prostate cancer condition (brief summary): _______________________________
  1. ;;
  1. ;; __________________________________________________________________________
  1. ;;^TOF^
  1. ;; b. Indicate status of disease:
  1. ;; ___ Active
  1. ;; ___ Remission
  1. ;;
  1. ;; 3. Treatment
  1. ;;
  1. ;; Has the Veteran completed any treatment for prostate cancer or is the
  1. ;; Veteran currently undergoing any treatment for prostate cancer?
  1. ;;
  1. ;; ___ Yes ___ No; watchful waiting
  1. ;;
  1. ;; If yes, indicate treatment type(s) (check all that apply):
  1. ;;
  1. ;; ___ Treatment completed; currently in watchful waiting status
  1. ;;
  1. ;; ___ Surgery
  1. ;; ___ Prostatectomy
  1. ;; ___ Other surgical procedure (describe): _____________________________
  1. ;; Date of surgery: __________
  1. ;;
  1. ;; ___ Radiation therapy
  1. ;; Date of completion of treatment or anticipated date of completion:_______
  1. ;;
  1. ;; ___ Brachytherapy
  1. ;; Date of treatment: __________
  1. ;;
  1. ;; ___ Antineoplastic chemotherapy
  1. ;; Date of most recent treatment: ______________
  1. ;; Date of completion of treatment or anticipated date of completion: ______
  1. ;;
  1. ;; ___ Androgen Deprivation Therapy (Hormonal Therapy)
  1. ;; Date of most recent treatment: ______________
  1. ;; Date of completion of treatment or anticipated date of completion: ______
  1. ;;
  1. ;; ___ Other therapeutic procedure and/or treatment (describe): ________________
  1. ;; Date of procedure: __________
  1. ;; Date of completion of treatment or anticipated date of completion: ______
  1. ;;
  1. ;;^TOF^
  1. ;; 4. Residual conditions and/or complications
  1. ;;
  1. ;; a. Does the Veteran have any residual conditions and/or complications due to
  1. ;; prostate cancer or treatment for prostate cancer?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following sections:
  1. ;;
  1. ;; b. Does the Veteran have voiding dysfunction causing urine leakage?
  1. ;; ___ Yes ___ No
  1. ;; If yes, check one:
  1. ;; ___ Does not require/does not use absorbent material
  1. ;; ___ Requires absorbent material that is changed less than 2 times per
  1. ;; day
  1. ;; ___ Requires absorbent material that is changed 2 to 4 times per day
  1. ;; ___ Requires absorbent material that is changed more than 4 times per
  1. ;; day
  1. ;;
  1. ;; c. Does the Veteran have voiding dysfunction causing signs and/or symptoms of
  1. ;; urinary frequency?
  1. ;; ___ Yes ___ No
  1. ;; If yes, check all that apply:
  1. ;; ___ Daytime voiding interval between 2 and 3 hours
  1. ;; ___ Daytime voiding interval between 1 and 2 hours
  1. ;; ___ Daytime voiding interval less than 1 hour
  1. ;; ___ Nighttime awakening to void 2 times
  1. ;; ___ Nighttime awakening to void 3 to 4 times
  1. ;; ___ Nighttime awakening to void 5 or more times
  1. ;;
  1. ;; d. Does the Veteran have voiding dysfunction causing findings, signs and/or
  1. ;; symptoms of obstructed voiding?
  1. ;; ___ Yes ___ No
  1. ;; If yes, check all signs and symptoms that apply:
  1. ;; ___ Hesitancy
  1. ;; If checked, is hesitancy marked?
  1. ;; ___ Yes ___ No
  1. ;; ___ Slow or weak stream
  1. ;; If checked, is stream markedly slow or weak?
  1. ;; ___ Yes ___ No
  1. ;; ___ Decreased force of stream
  1. ;; If checked, is force of stream markedly decreased?
  1. ;; ___ Yes ___ No
  1. ;; ___ Stricture disease requiring dilatation 1 to 2 times per year
  1. ;; ___ Stricture disease requiring periodic dilatation every 2 to 3
  1. ;; months
  1. ;; ___ Recurrent urinary tract infections secondary to obstruction
  1. ;; ___ Uroflowmetry peak flow rate less than 10 cc/sec
  1. ;; ___ Post void residuals greater than 150 cc
  1. ;; ___ Urinary retention requiring intermittent or continuous
  1. ;; catheterization
  1. ;;^TOF^
  1. ;; e. Does the Veteran have voiding dysfunction requiring the use of an
  1. ;; appliance?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe: ________________________________________________________
  1. ;;
  1. ;; f. Does the Veteran have a history of recurrent symptomatic urinary tract
  1. ;; infections?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, check all treatments that apply:
  1. ;; ___ No treatment
  1. ;; ___ Long-term drug therapy
  1. ;; If checked, list medications used for urinary tract infection and
  1. ;; indicate dates for courses of treatment over the past 12 months:
  1. ;;
  1. ;; ______________________________________________________________________
  1. ;;
  1. ;; ___ Hospitalization
  1. ;; If checked, indicate frequency of hospitalization:
  1. ;; ___ 1 or 2 per year
  1. ;; ___ More than 2 per year
  1. ;;
  1. ;; ___ Drainage
  1. ;; If checked, indicate dates when drainage performed over past 12
  1. ;; months: ________________
  1. ;;
  1. ;; ___ Intensive management
  1. ;; If checked, indicate frequency of management:
  1. ;; ___ Continuous
  1. ;; ___ Intermittent
  1. ;;
  1. ;; g. Does the Veteran have erectile dysfunction?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, is the erectile dysfunction as likely as not (at least a 50%
  1. ;; probability) attributable to prostate cancer, including treatment or
  1. ;; residuals of treatment for prostate cancer?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, provide the etiology of the erectile dysfunction: _____________
  1. ;; ______________________________________________________________________
  1. ;;
  1. ;; If yes, is the Veteran able to achieve an erection (without
  1. ;; medication) sufficient for penetration and ejaculation?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If no, is the Veteran able to achieve an erection (with medication)
  1. ;; sufficient for penetration and ejaculation?
  1. ;; ___ Yes ___ No
  1. ;;^TOF^
  1. ;; h. Does the Veteran have any other residual complications of prostate
  1. ;; cancer or treatment for prostate cancer?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, describe: ________________________________________________________
  1. ;;
  1. ;; 5. Other pertinent physical findings, complications, conditions, signs and/or
  1. ;; symptoms
  1. ;;
  1. ;; Does the Veteran have any other pertinent physical findings, complications,
  1. ;; conditions, signs and/or symptoms?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, describe: ___________________________________________________________
  1. ;;
  1. ;; 6. Diagnostic testing
  1. ;;
  1. ;; NOTE: If laboratory test results are in the medical record and reflect the
  1. ;; Veteran's current condition, repeat testing is not required.
  1. ;;
  1. ;; Are there any significant diagnostic test findings and/or results?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, provide type of test or procedure, date and results (brief summary):
  1. ;;
  1. ;; _____________________________________________________________________________
  1. ;;^TOF^
  1. ;; 7. Functional impact
  1. ;;
  1. ;; Does the Veteran's prostate cancer impact his ability to work?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, describe the impact of the Veteran's prostate cancer, providing one
  1. ;; or more examples: ___________________________________________________________
  1. ;;
  1. ;; _____________________________________________________________________________
  1. ;;
  1. ;; 8. Remarks, if any __________________________________________________________
  1. ;;
  1. ;; Physician signature: _____________________________________ Date: ____________
  1. ;;
  1. ;; Physician printed name: __________________________________ Phone: ___________
  1. ;;
  1. ;; Medical license #: __________________
  1. ;;
  1. ;; Physician address: __________________________________________________________
  1. ;;
  1. ;; NOTE: VA may request additional medical information, including additional
  1. ;; examinations if necessary to complete VA's review of the Veteran's
  1. ;; application.
  1. ;; ^END^
  1. Q