DVBCQPC4 ;;ALB-CIOFO/ECF - PROSTATE CANCER QUESTIONNAIRE ; 2/15/2011
;;2.7;AMIE;**163**;Apr 10, 1995;Build 5
;
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
;; prostate cancer condition (brief summary): _______________________________
;;
;; __________________________________________________________________________
;;
;; b. Indicate status of disease:
;; ___ Active
;; ___ Remission
;;^TOF^
;; 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
;; ___ Radical prostatectomy
;; ___ Transurethral resection prostatectomy
;; ___ Other (describe)______________________________________________
;; ___ 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 completion of treatment or anticipated date of
;; completion: _________________
;; ___ Androgen deprivation therapy (hormonal therapy)
;; 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. Voiding dysfunction
;;
;; Does the Veteran have a voiding dysfunction?
;; ___ Yes ___ No
;;
;; If yes, provide etiology of voiding dysfunction: ____________________________
;; If the Veteran has a voiding dysfunction, complete the following questions:
;;
;; a. Does the voiding dysfunction cause urine leakage?
;; ___ Yes ___ No
;
;; Indicate severity (check one):
;; ___ Does not require the wearing of absorbent material
;; ___ Requires absorbent material which must be changed less than 2
;; times per day
;; ___ Requires absorbent material which must be changed 2 to 4 times
;; per day
;; ___ Requires absorbent material which must be changed more than 4
;; times per day
;; ___ Other, describe: ____________________________________________________
;;
;; b. Does the voiding dysfunction require the use of an appliance?
;; ___ Yes ___ No
;;
;; If yes, describe the appliance: _____________________________________________
;;
;; c. Does the voiding dysfunction cause increased 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
;;^TOF^
;; d. Does the voiding dysfunction cause signs or symptoms of obstructed
;; voiding?
;; ___ Yes ___ No
;;
;; If yes, check all 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 catheterization
;; ___ Urinary retention requiring continuous catheterization
;; ___ Other, describe: _____________________________________________________
;;^TOF^
;; 5. Urinary tract/kidney infection
;;
;; Does the Veteran have a history of recurrent symptomatic urinary tract or
;; kidney infections?
;; ___ Yes ___ No
;;
;; If yes, provide etiology: ___________________________________________________
;;
;; If the Veteran has had recurrent symptomatic urinary tract or kidney
;; infections, indicate all treatment modalities that apply:
;; ___ No treatment
;; ___ Long-term drug therapy
;; If checked, list medications used and indicate dates for courses of
;; treatment over the past 12 months: ___________________________________
;; ______________________________________________________________________
;; ___ Hospitalization
;; If checked, indicate frequency of hospitalization:
;; ___ 1 or 2 per year
;; ___ > 2 per year
;; ___ Drainage
;; If checked, indicate dates when drainage performed over past 12
;; months: ______________________________________________________________
;; ___ Continuous intensive management
;; If checked, indicate types of treatment and medications used
;; over past 12 months: _________________________________________________
;; ___ Intermittent intensive management
;; If checked, indicate types of treatment and medications used
;; over past 12 months: _________________________________________________
;; ___ Other, describe: _____________________________________________________
;;^TOF^
;; 6. Erectile dysfunction
;;
;; a. Does the Veteran have erectile dysfunction?
;; ___ Yes ___ No
;;
;; If yes, provide etiology: ___________________________________________________
;;
;; b. If the Veteran has erectile dysfunction, is it as likely as not (at least
;; a 50% probability) attributable to one of the diagnoses in Section 1,
;; including residuals of treatment for this diagnosis?
;; ___ Yes ___ No
;;
;; If yes, specify the diagnosis to which the erectile dysfunction is as likely
;; as not attributable: ________________________________________________________
;;
;; c. If the Veteran has erectile dysfunction, is he able to achieve an erection
;; sufficient for penetration and ejaculation (without medication)?
;; ___ Yes ___ No
;;
;; If no, is the Veteran able to achieve an erection sufficient for penetration
;; and ejaculation (with medication)?
;; ___ Yes ___ No
;;
;; 7. Retrograde ejaculation
;;
;; a. Does the Veteran have retrograde ejaculation?
;; ___ Yes ___ No
;;
;; If yes, provide etiology of the retrograde ejaculation: _____________________
;;
;; b. If the Veteran has retrograde ejaculation, is it as likely as not (at
;; least a 50% probability) attributable to one of the diagnoses in Section 1,
;; including residuals of treatment for this diagnosis?
;; ___ Yes ___ No
;;
;; If yes, specify the diagnosis to which the retrograde ejaculation is as
;; likely as not attributable: _________________________________________________
;;
;; 8. Residual conditions and/or complications
;;
;; a. Does the Veteran have any other residual conditions and/or complications
;; due to prostate cancer or treatment for prostate cancer?
;; ___ Yes ___ No
;;
;; If yes, describe: ___________________________________________________________
;;^TOF^
;; 9. 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 or symptoms?
;; ___ Yes ___ No
;;
;; If yes, describe(brief summary): ____________________________________________
;;
;; 10. 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^
;; 11. 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: ___________________________________________________________
;;
;; _____________________________________________________________________________
;;
;; 12. Remarks, if any: ________________________________________________________
;;
;; Physician signature: _____________________________________ Date: ____________
;;
;; Physician printed name: __________________________________ Phone: ___________
;;
;; Medical license #: _______________________________________ Fax: _____________
;;
;; 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[HDVBCQPC4 11498 printed Apr 09, 2024@20:44:55 Page 2
DVBCQPC4 ;;ALB-CIOFO/ECF - PROSTATE CANCER QUESTIONNAIRE ; 2/15/2011
+1 ;;2.7;AMIE;**163**;Apr 10, 1995;Build 5
+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 ;; ___ Yes ___ No
+12 ;;
+13 ;; If no, provide rationale (e.g. Veteran has never had prostate cancer):
+14 ;;
+15 ;; _____________________________________________________________________________
+16 ;;
+17 ;; If yes, provide only diagnoses that pertain to prostate cancer.
+18 ;;
+19 ;; Diagnosis #1: ____________________
+20 ;; ICD code: ________________________
+21 ;; Date of diagnosis: _______________
+22 ;;
+23 ;; Diagnosis #2: ____________________
+24 ;; ICD code: ________________________
+25 ;; Date of diagnosis: _______________
+26 ;;
+27 ;; Diagnosis #3: ____________________
+28 ;; ICD code: ________________________
+29 ;; Date of diagnosis: _______________
+30 ;;
+31 ;; If there are additional diagnoses that pertain to prostate cancer, list using
+32 ;; above format: _______________________________________________________________
+33 ;;
+34 ;; 2. Medical history
+35 ;;
+36 ;; a. Describe the history (including onset and course) of the Veteran's
+37 ;; prostate cancer condition (brief summary): _______________________________
+38 ;;
+39 ;; __________________________________________________________________________
+40 ;;
+41 ;; b. Indicate status of disease:
+42 ;; ___ Active
+43 ;; ___ Remission
+44 ;;^TOF^
+45 ;; 3. Treatment
+46 ;;
+47 ;; Has the Veteran completed any treatment for prostate cancer or is the
+48 ;; Veteran currently undergoing any treatment for prostate cancer?
+49 ;; ___ Yes ___ No; watchful waiting
+50 ;;
+51 ;; If yes, indicate treatment type(s) (check all that apply):
+52 ;;
+53 ;; ___ Treatment completed; currently in watchful waiting status
+54 ;; ___ Surgery
+55 ;; ___ Prostatectomy
+56 ;; ___ Radical prostatectomy
+57 ;; ___ Transurethral resection prostatectomy
+58 ;; ___ Other (describe)______________________________________________
+59 ;; ___ Other surgical procedure (describe): _____________________________
+60 ;; Date of surgery: ____________
+61 ;; ___ Radiation therapy
+62 ;; Date of completion of treatment or anticipated date of
+63 ;; completion:__________________
+64 ;; ___ Brachytherapy
+65 ;; Date of treatment: __________
+66 ;; ___ Antineoplastic chemotherapy
+67 ;; Date of completion of treatment or anticipated date of
+68 ;; completion: _________________
+69 ;; ___ Androgen deprivation therapy (hormonal therapy)
+70 ;; Date of completion of treatment or anticipated date of
+71 ;; completion: _________________
+72 ;; ___ Other therapeutic procedure and/or treatment (describe): _____________
+73 ;; ______________________________________________________________________
+74 ;; Date of procedure: __________
+75 ;; Date of completion of treatment or anticipated date of
+76 ;; completion: _________________
+77 ;;^TOF^
+78 ;; 4. Voiding dysfunction
+79 ;;
+80 ;; Does the Veteran have a voiding dysfunction?
+81 ;; ___ Yes ___ No
+82 ;;
+83 ;; If yes, provide etiology of voiding dysfunction: ____________________________
+84 ;; If the Veteran has a voiding dysfunction, complete the following questions:
+85 ;;
+86 ;; a. Does the voiding dysfunction cause urine leakage?
+87 ;; ___ Yes ___ No
+88 ;
+89 ;; Indicate severity (check one):
+90 ;; ___ Does not require the wearing of absorbent material
+91 ;; ___ Requires absorbent material which must be changed less than 2
+92 ;; times per day
+93 ;; ___ Requires absorbent material which must be changed 2 to 4 times
+94 ;; per day
+95 ;; ___ Requires absorbent material which must be changed more than 4
+96 ;; times per day
+97 ;; ___ Other, describe: ____________________________________________________
+98 ;;
+99 ;; b. Does the voiding dysfunction require the use of an appliance?
+100 ;; ___ Yes ___ No
+101 ;;
+102 ;; If yes, describe the appliance: _____________________________________________
+103 ;;
+104 ;; c. Does the voiding dysfunction cause increased urinary frequency?
+105 ;; ___ Yes ___ No
+106 ;;
+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 ;;^TOF^
+115 ;; d. Does the voiding dysfunction cause signs or symptoms of obstructed
+116 ;; voiding?
+117 ;; ___ Yes ___ No
+118 ;;
+119 ;; If yes, check all that apply:
+120 ;; ___ Hesitancy
+121 ;; If checked, is hesitancy marked?
+122 ;; ___ Yes ___ No
+123 ;; ___ Slow or weak stream
+124 ;; If checked, is stream markedly slow or weak?
+125 ;; ___ Yes ___ No
+126 ;; ___ Decreased force of stream
+127 ;; If checked, is force of stream markedly decreased?
+128 ;; ___ Yes ___ No
+129 ;; ___ Stricture disease requiring dilatation 1 to 2 times per year
+130 ;; ___ Stricture disease requiring periodic dilatation every 2 to 3
+131 ;; months
+132 ;; ___ Recurrent urinary tract infections secondary to obstruction
+133 ;; ___ Uroflowmetry peak flow rate less than 10 cc/sec
+134 ;; ___ Post void residuals greater than 150 cc
+135 ;; ___ Urinary retention requiring intermittent catheterization
+136 ;; ___ Urinary retention requiring continuous catheterization
+137 ;; ___ Other, describe: _____________________________________________________
+138 ;;^TOF^
+139 ;; 5. Urinary tract/kidney infection
+140 ;;
+141 ;; Does the Veteran have a history of recurrent symptomatic urinary tract or
+142 ;; kidney infections?
+143 ;; ___ Yes ___ No
+144 ;;
+145 ;; If yes, provide etiology: ___________________________________________________
+146 ;;
+147 ;; If the Veteran has had recurrent symptomatic urinary tract or kidney
+148 ;; infections, indicate all treatment modalities that apply:
+149 ;; ___ No treatment
+150 ;; ___ Long-term drug therapy
+151 ;; If checked, list medications used and indicate dates for courses of
+152 ;; treatment over the past 12 months: ___________________________________
+153 ;; ______________________________________________________________________
+154 ;; ___ Hospitalization
+155 ;; If checked, indicate frequency of hospitalization:
+156 ;; ___ 1 or 2 per year
+157 ;; ___ > 2 per year
+158 ;; ___ Drainage
+159 ;; If checked, indicate dates when drainage performed over past 12
+160 ;; months: ______________________________________________________________
+161 ;; ___ Continuous intensive management
+162 ;; If checked, indicate types of treatment and medications used
+163 ;; over past 12 months: _________________________________________________
+164 ;; ___ Intermittent intensive management
+165 ;; If checked, indicate types of treatment and medications used
+166 ;; over past 12 months: _________________________________________________
+167 ;; ___ Other, describe: _____________________________________________________
+168 ;;^TOF^
+169 ;; 6. Erectile dysfunction
+170 ;;
+171 ;; a. Does the Veteran have erectile dysfunction?
+172 ;; ___ Yes ___ No
+173 ;;
+174 ;; If yes, provide etiology: ___________________________________________________
+175 ;;
+176 ;; b. If the Veteran has erectile dysfunction, is it as likely as not (at least
+177 ;; a 50% probability) attributable to one of the diagnoses in Section 1,
+178 ;; including residuals of treatment for this diagnosis?
+179 ;; ___ Yes ___ No
+180 ;;
+181 ;; If yes, specify the diagnosis to which the erectile dysfunction is as likely
+182 ;; as not attributable: ________________________________________________________
+183 ;;
+184 ;; c. If the Veteran has erectile dysfunction, is he able to achieve an erection
+185 ;; sufficient for penetration and ejaculation (without medication)?
+186 ;; ___ Yes ___ No
+187 ;;
+188 ;; If no, is the Veteran able to achieve an erection sufficient for penetration
+189 ;; and ejaculation (with medication)?
+190 ;; ___ Yes ___ No
+191 ;;
+192 ;; 7. Retrograde ejaculation
+193 ;;
+194 ;; a. Does the Veteran have retrograde ejaculation?
+195 ;; ___ Yes ___ No
+196 ;;
+197 ;; If yes, provide etiology of the retrograde ejaculation: _____________________
+198 ;;
+199 ;; b. If the Veteran has retrograde ejaculation, is it as likely as not (at
+200 ;; least a 50% probability) attributable to one of the diagnoses in Section 1,
+201 ;; including residuals of treatment for this diagnosis?
+202 ;; ___ Yes ___ No
+203 ;;
+204 ;; If yes, specify the diagnosis to which the retrograde ejaculation is as
+205 ;; likely as not attributable: _________________________________________________
+206 ;;
+207 ;; 8. Residual conditions and/or complications
+208 ;;
+209 ;; a. Does the Veteran have any other residual conditions and/or complications
+210 ;; due to prostate cancer or treatment for prostate cancer?
+211 ;; ___ Yes ___ No
+212 ;;
+213 ;; If yes, describe: ___________________________________________________________
+214 ;;^TOF^
+215 ;; 9. Other pertinent physical findings, complications, conditions, signs and/or
+216 ;; symptoms
+217 ;;
+218 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+219 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+220 ;; section above?
+221 ;; ___ Yes ___ No
+222 ;;
+223 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+224 ;; of all related scars greater than 39 square cm (6 square inches)?
+225 ;; ___ Yes ___ No
+226 ;; If yes, also complete a Scars Questionnaire.
+227 ;;
+228 ;; b. Does the Veteran have any other pertinent physical findings,
+229 ;; complications, conditions, signs or symptoms?
+230 ;; ___ Yes ___ No
+231 ;;
+232 ;; If yes, describe(brief summary): ____________________________________________
+233 ;;
+234 ;; 10. Diagnostic testing
+235 ;;
+236 ;; NOTE: If laboratory test results are in the medical record and reflect the
+237 ;; Veteran's current condition, repeat testing is not required.
+238 ;;
+239 ;; Are there any significant diagnostic test findings and/or results?
+240 ;; ___ Yes ___ No
+241 ;;
+242 ;; If yes, provide type of test or procedure, date and results (brief summary):
+243 ;;
+244 ;; _____________________________________________________________________________
+245 ;;^TOF^
+246 ;; 11. Functional impact
+247 ;;
+248 ;; Does the Veteran's prostate cancer impact his ability to work?
+249 ;; ___ Yes ___ No
+250 ;;
+251 ;; If yes, describe the impact of the Veteran's prostate cancer, providing one
+252 ;; or more examples: ___________________________________________________________
+253 ;;
+254 ;; _____________________________________________________________________________
+255 ;;
+256 ;; 12. Remarks, if any: ________________________________________________________
+257 ;;
+258 ;; Physician signature: _____________________________________ Date: ____________
+259 ;;
+260 ;; Physician printed name: __________________________________ Phone: ___________
+261 ;;
+262 ;; Medical license #: _______________________________________ Fax: _____________
+263 ;;
+264 ;; Physician address: __________________________________________________________
+265 ;;
+266 ;; NOTE: VA may request additional medical information, including additional
+267 ;; examinations if necessary to complete VA's review of the Veteran's
+268 ;; application.
+269 ;; ^END^
+270 QUIT
