Home   Package List   Routine Alphabetical List   Global Alphabetical List   FileMan Files List   FileMan Sub-Files List   Package Component Lists   Package-Namespace Mapping  
Routine: DVBCQPC4

DVBCQPC4.m

Go to the documentation of this file. 
  1. DVBCQPC4 ;;ALB-CIOFO/ECF - PROSTATE CANCER QUESTIONNAIRE ; 2/15/2011
  1.  ;;2.7;AMIE;**163**;Apr 10, 1995;Build 5
  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.  ;; ___ 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.  ;; ICD code: ________________________
  1.  ;; Date of diagnosis: _______________
  1.  ;;
  1.  ;; Diagnosis #2: ____________________
  1.  ;; ICD code: ________________________
  1.  ;; Date of diagnosis: _______________
  1.  ;;
  1.  ;; Diagnosis #3: ____________________
  1.  ;; ICD code: ________________________
  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
  1.  ;;    prostate cancer condition (brief summary): _______________________________
  1.  ;;
  1.  ;;    __________________________________________________________________________
  1.  ;;
  1.  ;; b. Indicate status of disease:
  1.  ;;    ___ Active
  1.  ;;    ___ Remission
  1.  ;;^TOF^
  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.  ;; ___ 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.  ;;    ___ Surgery
  1.  ;;        ___ Prostatectomy
  1.  ;;            ___ Radical prostatectomy
  1.  ;;            ___ Transurethral resection prostatectomy
  1.  ;;            ___ Other (describe)______________________________________________
  1.  ;;        ___ Other surgical procedure (describe): _____________________________
  1.  ;;        Date of surgery: ____________
  1.  ;;    ___ Radiation therapy
  1.  ;;        Date of completion of treatment or anticipated date of
  1.  ;;        completion:__________________
  1.  ;;    ___ Brachytherapy
  1.  ;;        Date of treatment: __________
  1.  ;;    ___ Antineoplastic chemotherapy
  1.  ;;        Date of completion of treatment or anticipated date of
  1.  ;;        completion: _________________
  1.  ;;    ___ Androgen deprivation therapy (hormonal therapy)
  1.  ;;        Date of completion of treatment or anticipated date of
  1.  ;;        completion: _________________
  1.  ;;    ___ Other therapeutic procedure and/or treatment (describe): _____________
  1.  ;;        ______________________________________________________________________
  1.  ;;        Date of procedure: __________
  1.  ;;        Date of completion of treatment or anticipated date of
  1.  ;;        completion: _________________
  1.  ;;^TOF^
  1.  ;; 4. Voiding dysfunction
  1.  ;;
  1.  ;; Does the Veteran have a voiding dysfunction?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide etiology of voiding dysfunction: ____________________________
  1.  ;; If the Veteran has a voiding dysfunction, complete the following questions:
  1.  ;;
  1.  ;; a. Does the voiding dysfunction cause urine leakage?
  1.  ;; ___ Yes   ___ No
  1.  ;
  1.  ;; Indicate severity (check one):
  1.  ;;     ___ Does not require the wearing of absorbent material
  1.  ;;     ___ Requires absorbent material which must be changed less than 2
  1.  ;;         times per day
  1.  ;;     ___ Requires absorbent material which must be changed 2 to 4 times
  1.  ;;         per day
  1.  ;;     ___ Requires absorbent material which must be changed more than 4
  1.  ;;         times per day
  1.  ;;     ___ Other, describe: ____________________________________________________
  1.  ;;
  1.  ;; b. Does the voiding dysfunction require the use of an appliance?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe the appliance: _____________________________________________
  1.  ;;
  1.  ;; c. Does the voiding dysfunction cause increased urinary frequency?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  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.  ;;^TOF^
  1.  ;; d. Does the voiding dysfunction cause signs or symptoms of obstructed
  1.  ;; voiding?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, check all 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 catheterization
  1.  ;;    ___ Urinary retention requiring continuous catheterization
  1.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;^TOF^
  1.  ;; 5. Urinary tract/kidney infection
  1.  ;;
  1.  ;; Does the Veteran have a history of recurrent symptomatic urinary tract or
  1.  ;; kidney infections?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide etiology: ___________________________________________________
  1.  ;;
  1.  ;; If the Veteran has had recurrent symptomatic urinary tract or kidney
  1.  ;; infections, indicate all treatment modalities that apply:
  1.  ;;    ___ No treatment
  1.  ;;    ___ Long-term drug therapy
  1.  ;;        If checked, list medications used and indicate dates for courses of
  1.  ;;        treatment over the past 12 months: ___________________________________
  1.  ;;        ______________________________________________________________________
  1.  ;;    ___ Hospitalization
  1.  ;;        If checked, indicate frequency of hospitalization:
  1.  ;;        ___ 1 or 2 per year
  1.  ;;        ___ > 2 per year
  1.  ;;    ___ Drainage
  1.  ;;        If checked, indicate dates when drainage performed over past 12
  1.  ;;        months: ______________________________________________________________
  1.  ;;    ___ Continuous intensive management
  1.  ;;        If checked, indicate types of treatment and medications used
  1.  ;;        over past 12 months: _________________________________________________
  1.  ;;    ___ Intermittent intensive management
  1.  ;;        If checked, indicate types of treatment and medications used
  1.  ;;        over past 12 months: _________________________________________________
  1.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;^TOF^
  1.  ;; 6. Erectile dysfunction
  1.  ;;
  1.  ;; a. Does the Veteran have erectile dysfunction?
  1.  ;;  ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide etiology: ___________________________________________________
  1.  ;; 
  1.  ;; b. If the Veteran has erectile dysfunction, is it as likely as not (at least
  1.  ;; a 50% probability) attributable to one of the diagnoses in Section 1,
  1.  ;; including residuals of treatment for this diagnosis?
  1.  ;;  ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, specify the diagnosis to which the erectile dysfunction is as likely
  1.  ;; as not attributable: ________________________________________________________
  1.  ;;
  1.  ;; c. If the Veteran has erectile dysfunction, is he able to achieve an erection
  1.  ;; sufficient for penetration and ejaculation (without medication)?
  1.  ;;  ___ Yes   ___ No
  1.  ;;
  1.  ;; If no, is the Veteran able to achieve an erection sufficient for penetration
  1.  ;; and ejaculation (with medication)?
  1.  ;;  ___ Yes   ___ No
  1.  ;;
  1.  ;; 7. Retrograde ejaculation
  1.  ;;
  1.  ;; a. Does the Veteran have retrograde ejaculation?
  1.  ;;  ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide etiology of the retrograde ejaculation: _____________________
  1.  ;;
  1.  ;; b. If the Veteran has retrograde ejaculation, is it as likely as not (at
  1.  ;; least a 50% probability) attributable to one of the diagnoses in Section 1,
  1.  ;; including residuals of treatment for this diagnosis?
  1.  ;;  ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, specify the diagnosis to which the retrograde ejaculation is as
  1.  ;; likely as not attributable: _________________________________________________
  1.  ;;
  1.  ;; 8. Residual conditions and/or complications
  1.  ;;
  1.  ;; a. Does the Veteran have any other residual conditions and/or complications 
  1.  ;; due to prostate cancer or treatment for prostate cancer?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe: ___________________________________________________________
  1.  ;;^TOF^
  1.  ;; 9. Other pertinent physical findings, complications, conditions, signs and/or
  1.  ;; symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;;    If yes, are any of the scars painful and/or unstable, or is the total area
  1.  ;;    of all related scars greater than 39 square cm (6 square inches)?
  1.  ;;    ___ Yes   ___ No
  1.  ;;    If yes, also complete a Scars Questionnaire.
  1.  ;; 
  1.  ;; b. Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs or symptoms?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe(brief summary): ____________________________________________
  1.  ;;
  1.  ;; 10. 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.  ;; 11. 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.  ;; 12. Remarks, if any: ________________________________________________________
  1.  ;;
  1.  ;; Physician signature: _____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: __________________________________ Phone: ___________
  1.  ;;
  1.  ;; Medical license #: _______________________________________ Fax: _____________
  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