Home   Package List   Routine Alphabetical List   Global Alphabetical List   FileMan Files List   FileMan Sub-Files List   Package Component Lists   Package-Namespace Mapping  
Routine: DVBCQPG2

DVBCQPG2.m

Go to the documentation of this file. 
  1. DVBCQPG2 ;;ALB-CIOFO/ECF,SBW -  PERSION GULF & AFGHANISTAN INFECTION DISEASE QUESTIONNAIRE ; 4/APR/2011
  1.  ;;2.7;AMIE;**166**;Apr 10, 1995;Build 6
  1.  ;
  1. TXT ;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1.  ;; disability benefits.  VA will consider the information you provide on this
  1.  ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1.  ;;
  1.  ;; NOTE: This questionnaire is intended solely for claims based on 38 CFR 3.317(c)
  1.  ;; Presumptive service connection for infectious disease. Therefore, this
  1.  ;; questionnaire should only be completed for Veterans who have or have had one
  1.  ;; or more of the following diseases/infections of the following agents:
  1.  ;; brucellosis, campylobacteriosis (Campylobacter jejuni), Q-fever (Coxiella
  1.  ;; burnetii), malaria, tuberculosis (Mycobacterium tuberculosis), nontyphoid
  1.  ;; Salmonella, shigellosis (Shigella), visceral leishmaniasis, or West Nile virus.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with any of the
  1.  ;; infectious diseases listed above?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, indicate the infectious disease(s)/agent(s) that the Veteran now has
  1.  ;; or has been diagnosed with:
  1.  ;; ___ brucellosis
  1.  ;;     ICD code:  __________  Date of diagnosis: _______________
  1.  ;; ___ Campylobacter jejuni
  1.  ;;     ICD code:  __________  Date of diagnosis: _______________
  1.  ;; ___ Coxiella burnetii (Q-fever)
  1.  ;;     ICD code:  __________  Date of diagnosis: _______________
  1.  ;; ___ malaria
  1.  ;;     ICD code:  __________  Date of diagnosis: _______________
  1.  ;; ___ nontyphoid Salmonella
  1.  ;;     ICD code:  __________  Date of diagnosis: _______________
  1.  ;; ___ Shigella
  1.  ;;     ICD code:  __________  Date of diagnosis: _______________
  1.  ;; ___ visceral leishmaniasis
  1.  ;;     ICD code:  __________  Date of diagnosis: _______________
  1.  ;; ___ West Nile virus
  1.  ;;     ICD code:  __________  Date of diagnosis: _______________
  1.  ;; ___ Mycobacterium tuberculosis (TB)
  1.  ;; If TB is the only diagnosis checked, do not complete the rest of this
  1.  ;; Questionnaire; instead, complete the Tuberculosis Questionnaire.
  1.  ;;
  1.  ;; If any other disease(s) have been checked along with mycobacterium
  1.  ;; tuberculosis, complete the Tuberculosis Questionnaire for all tuberculosis-
  1.  ;; related conditions, and also complete this Questionnaire (Persian Gulf and
  1.  ;; Afghanistan Infectious Diseases) for all other non-tuberculosis related
  1.  ;; diseases checked above.
  1.  ;;^TOF^
  1.  ;; 2. Medical history for disease #1
  1.  ;; a. Name of disease #1: _________________________
  1.  ;; Describe the history (including onset and course) of the Veteran's disease #1:
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; b. Status of disease #1:
  1.  ;; ___ Active
  1.  ;; ___ Inactive/treated and resolved
  1.  ;;
  1.  ;; c. If inactive, date disease became inactive/resolved: ______________________
  1.  ;;
  1.  ;; d. If inactive/resolved, are there residuals due to the disease?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe residuals: _________________________________________________
  1.  ;; Also complete appropriate Questionnaire for each specific residual condition,
  1.  ;; if indicated.
  1.  ;;
  1.  ;; 3. Medical history for disease #2
  1.  ;; a. Name of disease #2: _________________________
  1.  ;; Describe the history (including onset and course) of the Veteran's disease #2:
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; b. Status of disease #2:
  1.  ;; ___ Active
  1.  ;; ___ Inactive/treated and resolved
  1.  ;;
  1.  ;; c. If inactive, date disease became inactive/resolved: ______________________
  1.  ;;
  1.  ;; d. If inactive/resolved, are there residuals due to the disease?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe residuals: _________________________________________________
  1.  ;; Also complete appropriate Questionnaire for each specific residual condition,
  1.  ;; if indicated.
  1.  ;;
  1.  ;; 4. Medical history for disease #3
  1.  ;; a. Name of disease #3: _________________________
  1.  ;; Describe the history (including onset and course) of the Veteran's disease #3:
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; b. Status of disease #3:
  1.  ;; ___ Active
  1.  ;; ___ Inactive/treated and resolved
  1.  ;;
  1.  ;; c. If inactive, date disease became inactive/resolved: ______________________
  1.  ;;
  1.  ;; d. If inactive/resolved, are there residuals due to the disease?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe residuals: ______________________
  1.  ;; Also complete appropriate Questionnaire for each specific residual condition,
  1.  ;; if indicated.
  1.  ;;^TOF^
  1.  ;; 5. Additional Gulf War infectious diseases
  1.  ;; If the Veteran has had any additional Gulf War infectious diseases, describe
  1.  ;; using above format: _________________________________________________________
  1.  ;;
  1.  ;; 6. Other pertinent physical findings, complications, conditions, signs and/or
  1.  ;; symptoms
  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.  ;; 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.  ;; If yes, describe (brief summary): __________________________________________
  1.  ;;
  1.  ;; 7. Diagnostic testing
  1.  ;; NOTE: If the Veteran has had diagnostic testing for suspected or confirmed
  1.  ;; Gulf War infectious diseases and the results are in the medical record and
  1.  ;; reflect the Veteran's current status, repeat testing is not indicated.
  1.  ;;
  1.  ;; Are there any significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 8. Functional impact
  1.  ;; Does the Veteran's Gulf War infectious disease(s) impact his or her ability
  1.  ;; to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe impact of each of the Veteran's Gulf War infectious
  1.  ;; diseases, providing one or more examples:
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 9. Remarks, if any: _________________________________________________________
  1.  ;;
  1.  ;; Physician signature: _____________________________________ Date: ____________
  1.  ;; Physician printed name: _____________________________________________________
  1.  ;; Medical license #: __________________________________________________________
  1.  ;; Physician address: __________________________________________________________
  1.  ;; Phone: _____________________________     FAX: _______________________________
  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