DVBCQPC6 ;;ALB-CIOFO/ECF - PROSTATE CANCER QUESTIONNAIRE (V3) ; 6/15/2011
;;2.7;AMIE;**169**;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 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:
;; _____________________________
;;
;; 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: _____________________________________________________
;;^TOF^
;; 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
;;
;; 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: __________________________________________________
;;
;; 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: __________________________________________________
;;^TOF^
;; 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: ____________________________________________________
;;
;; 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: ____________________
;;^TOF^
;; 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: ________________________________________
;;
;; 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: ____________________________________________________
;;
;; Medical license #: _________________________________________________________
;;
;; Physician address: _________________________________________________________
;;
;; Phone: ____________________________ FAX: _______________________________
;;
;; 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[HDVBCQPC6 11063 printed Apr 09, 2024@20:45:02 Page 2
DVBCQPC6 ;;ALB-CIOFO/ECF - PROSTATE CANCER QUESTIONNAIRE (V3) ; 6/15/2011
+1 ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+2 ;; (VA) for disability benefits. VA will consider the information you
+3 ;; provide on this questionnaire as part of their evaluation in processing
+4 ;; the Veteran's claim.
+5 ;;
+6 ;; 1. Diagnosis
+7 ;;
+8 ;; Does the Veteran now have or has he ever been diagnosed with prostate
+9 ;; cancer?
+10 ;; ___ Yes ___ No
+11 ;;
+12 ;; If yes, provide only diagnoses that pertain to prostate cancer.
+13 ;; Diagnosis #1: ____________________
+14 ;; ICD code: ________________________
+15 ;; Date of diagnosis: _______________
+16 ;;
+17 ;; Diagnosis #2: ____________________
+18 ;; ICD code: ________________________
+19 ;; Date of diagnosis: _______________
+20 ;;
+21 ;; Diagnosis #3: ____________________
+22 ;; ICD code: ________________________
+23 ;; Date of diagnosis: _______________
+24 ;;
+25 ;; If there are additional diagnoses that pertain to prostate cancer, list
+26 ;; using above format: ________________________________________________________
+27 ;;
+28 ;; 2. Medical history
+29 ;;
+30 ;; a. Describe the history (including onset and course) of the Veteran's
+31 ;; prostate cancer condition (brief summary): _________________________________
+32 ;;
+33 ;; b. Indicate status of disease:
+34 ;; ___ Active
+35 ;; ___ Remission
+36 ;;^TOF^
+37 ;; 3. Treatment
+38 ;;
+39 ;; Has the Veteran completed any treatment for prostate cancer or is the
+40 ;; Veteran currently undergoing any treatment for prostate cancer?
+41 ;; ___ Yes ___ No; watchful waiting
+42 ;; If yes, indicate treatment type(s) (check all that apply):
+43 ;; ___ Treatment completed; currently in watchful waiting status
+44 ;; ___ Surgery
+45 ;; ___ Prostatectomy
+46 ;; ___ Radical prostatectomy
+47 ;; ___ Transurethral resection prostatectomy
+48 ;; ___ Other (describe)_________________________________________
+49 ;; ___ Other surgical procedure (describe): ____________________________
+50 ;; Date of surgery: ____________
+51 ;; ___ Radiation therapy
+52 ;; Date of completion of treatment or anticipated date of completion:
+53 ;; _____________________________
+54 ;; ___ Brachytherapy
+55 ;; Date of treatment: __________
+56 ;; ___ Antineoplastic chemotherapy
+57 ;; Date of completion of treatment or anticipated date of completion:
+58 ;; _____________________________
+59 ;; ___ Androgen deprivation therapy (hormonal therapy)
+60 ;; Date of completion of treatment or anticipated date of completion:
+61 ;; _____________________________
+62 ;; ___ Other therapeutic procedure and/or treatment (describe): ____________
+63 ;; Date of procedure: __________
+64 ;; Date of completion of treatment or anticipated date of completion:
+65 ;; _____________________________
+66 ;;
+67 ;; 4. Voiding dysfunction
+68 ;;
+69 ;; Does the Veteran have a voiding dysfunction?
+70 ;; ___ Yes ___ No
+71 ;; If yes, provide etiology of voiding dysfunction: ___________________________
+72 ;; If the Veteran has a voiding dysfunction, complete the following questions:
+73 ;;
+74 ;; a. Does the voiding dysfunction cause urine leakage?
+75 ;; ___ Yes ___ No
+76 ;; Indicate severity (check one):
+77 ;; ___ Does not require the wearing of absorbent material
+78 ;; ___ Requires absorbent material which must be changed less than 2 times
+79 ;; per day
+80 ;; ___ Requires absorbent material which must be changed 2 to 4 times per
+81 ;; day
+82 ;; ___ Requires absorbent material which must be changed more than 4 times
+83 ;; per day
+84 ;; ___ Other, describe: _____________________________________________________
+85 ;;^TOF^
+86 ;; b. Does the voiding dysfunction require the use of an appliance?
+87 ;; ___ Yes ___ No
+88 ;; If yes, describe the appliance: ____________________________________________
+89 ;; ____________________________________________________________________________
+90 ;;
+91 ;; c. Does the voiding dysfunction cause increased urinary frequency?
+92 ;; ___ Yes ___ No
+93 ;; If yes, check all that apply:
+94 ;; ___ Daytime voiding interval between 2 and 3 hours
+95 ;; ___ Daytime voiding interval between 1 and 2 hours
+96 ;; ___ Daytime voiding interval less than 1 hour
+97 ;; ___ Nighttime awakening to void 2 times
+98 ;; ___ Nighttime awakening to void 3 to 4 times
+99 ;; ___ Nighttime awakening to void 5 or more times
+100 ;;
+101 ;; d. Does the voiding dysfunction cause signs or symptoms of obstructed
+102 ;; voiding?
+103 ;; ___ Yes ___ No
+104 ;; If yes, check all that apply:
+105 ;; ___ Hesitancy
+106 ;; If checked, is hesitancy marked?
+107 ;; ___ Yes ___ No
+108 ;; ___ Slow or weak stream
+109 ;; If checked, is stream markedly slow or weak?
+110 ;; ___ Yes ___ No
+111 ;; ___ Decreased force of stream
+112 ;; If checked, is force of stream markedly decreased?
+113 ;; ___ Yes ___ No
+114 ;; ___ Stricture disease requiring dilatation 1 to 2 times per year
+115 ;; ___ Stricture disease requiring periodic dilatation every 2 to 3 months
+116 ;; ___ Recurrent urinary tract infections secondary to obstruction
+117 ;; ___ Uroflowmetry peak flow rate less than 10 cc/sec
+118 ;; ___ Post void residuals greater than 150 cc
+119 ;; ___ Urinary retention requiring intermittent catheterization
+120 ;; ___ Urinary retention requiring continuous catheterization
+121 ;; ___ Other, describe: __________________________________________________
+122 ;;
+123 ;; 5. Urinary tract/kidney infection
+124 ;;
+125 ;; Does the Veteran have a history of recurrent symptomatic urinary tract or
+126 ;; kidney infections?
+127 ;; ___ Yes ___ No
+128 ;; If yes, provide etiology: __________________________________________________
+129 ;;^TOF^
+130 ;; If the Veteran has had recurrent symptomatic urinary tract or kidney
+131 ;; infections, indicate all treatment modalities that apply:
+132 ;; ___ No treatment
+133 ;; ___ Long-term drug therapy
+134 ;; If checked, list medications used and indicate dates for courses of
+135 ;; treatment over the past 12 months: __________________________________
+136 ;; ___ Hospitalization
+137 ;; If checked, indicate frequency of hospitalization:
+138 ;; ___ 1 or 2 per year
+139 ;; ___ > 2 per year
+140 ;; ___ Drainage
+141 ;; If checked, indicate dates when drainage performed over past
+142 ;; 12 months:___________________________________________________________
+143 ;; ___ Continuous intensive management
+144 ;; If checked, indicate types of treatment and medications used over
+145 ;; past 12 months: _____________________________________________________
+146 ;; ___ Intermittent intensive management
+147 ;; If checked, indicate types of treatment and medications used over
+148 ;; past 12 months: _____________________________________________________
+149 ;; ___ Other, describe: ____________________________________________________
+150 ;;
+151 ;; 6. Erectile dysfunction
+152 ;;
+153 ;; a. Does the Veteran have erectile dysfunction?
+154 ;; ___ Yes ___ No
+155 ;; If yes, provide etiology: __________________________________________________
+156 ;;
+157 ;; b. If the Veteran has erectile dysfunction, is it as likely as not (at least
+158 ;; a 50% probability) attributable to one of the diagnoses in Section 1,
+159 ;; including residuals of treatment for this diagnosis?
+160 ;; ___ Yes ___ No
+161 ;; If yes, specify the diagnosis to which the erectile dysfunction is as likely
+162 ;; as not attributable: _______________________________________________________
+163 ;;
+164 ;; c. If the Veteran has erectile dysfunction, is he able to achieve an
+165 ;; erection sufficient for penetration and ejaculation (without medication)?
+166 ;; ___ Yes ___ No
+167 ;; If no, is the Veteran able to achieve an erection sufficient for penetration
+168 ;; and ejaculation (with medication)?
+169 ;; ___ Yes ___ No
+170 ;;
+171 ;; 7. Retrograde ejaculation
+172 ;;
+173 ;; a. Does the Veteran have retrograde ejaculation?
+174 ;; ___ Yes ___ No
+175 ;; If yes, provide etiology of the retrograde ejaculation: ____________________
+176 ;;^TOF^
+177 ;; b. If the Veteran has retrograde ejaculation, is it as likely as not (at
+178 ;; least a 50% probability) attributable to one of the diagnoses in Section 1,
+179 ;; including residuals of treatment for this diagnosis?
+180 ;; ___ Yes ___ No
+181 ;; If yes, specify the diagnosis to which the retrograde ejaculation is as
+182 ;; likely as not attributable: ________________________________________________
+183 ;;
+184 ;; 8. Residual conditions and/or complications
+185 ;;
+186 ;; a. Does the Veteran have any other residual conditions and/or complications
+187 ;; due to prostate cancer or treatment for prostate cancer?
+188 ;; ___ Yes ___ No
+189 ;; If yes, describe: ________________________________________
+190 ;;
+191 ;; 9. Other pertinent physical findings, complications, conditions, signs
+192 ;; and/or symptoms
+193 ;;
+194 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+195 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+196 ;; section above?
+197 ;; ___ Yes ___ No
+198 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+199 ;; of all related scars greater than 39 square cm (6 square inches)?
+200 ;; ___ Yes ___ No
+201 ;; If yes, also complete a Scars Questionnaire.
+202 ;;
+203 ;; b. Does the Veteran have any other pertinent physical findings,
+204 ;; complications, conditions, signs or symptoms?
+205 ;; ___ Yes ___ No
+206 ;; If yes, describe (brief summary): __________________________________________
+207 ;;
+208 ;; 10. Diagnostic testing
+209 ;;
+210 ;; NOTE: If laboratory test results are in the medical record and reflect the
+211 ;; Veteran's current condition, repeat testing is not required.
+212 ;;
+213 ;; Are there any significant diagnostic test findings and/or results?
+214 ;; ___ Yes ___ No
+215 ;; If yes, provide type of test or procedure, date and results (brief summary):
+216 ;; ____________________________________________________________________________
+217 ;;^TOF^
+218 ;; 11. Functional impact
+219 ;;
+220 ;; Does the Veteran's prostate cancer impact his ability to work?
+221 ;; ___ Yes ___ No
+222 ;; If yes, describe the impact of the Veteran's prostate cancer, providing one
+223 ;; or more examples: __________________________________________________________
+224 ;;
+225 ;; 12. Remarks, if any: _______________________________________________________
+226 ;;
+227 ;; Physician signature: ____________________________________ Date: ____________
+228 ;;
+229 ;; Physician printed name: ____________________________________________________
+230 ;;
+231 ;; Medical license #: _________________________________________________________
+232 ;;
+233 ;; Physician address: _________________________________________________________
+234 ;;
+235 ;; Phone: ____________________________ FAX: _______________________________
+236 ;;
+237 ;; NOTE: VA may request additional medical information, including additional
+238 ;; examinations if necessary to complete VA's review of the Veteran's
+239 ;; application.
+240 ;;
+241 ;;^END^
+242 QUIT
