DVBCQPG2 ;;ALB-CIOFO/ECF,SBW - PERSION GULF & AFGHANISTAN INFECTION DISEASE QUESTIONNAIRE ; 4/APR/2011
;;2.7;AMIE;**166**;Apr 10, 1995;Build 6
;
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.
;;
;; NOTE: This questionnaire is intended solely for claims based on 38 CFR 3.317(c)
;; Presumptive service connection for infectious disease. Therefore, this
;; questionnaire should only be completed for Veterans who have or have had one
;; or more of the following diseases/infections of the following agents:
;; brucellosis, campylobacteriosis (Campylobacter jejuni), Q-fever (Coxiella
;; burnetii), malaria, tuberculosis (Mycobacterium tuberculosis), nontyphoid
;; Salmonella, shigellosis (Shigella), visceral leishmaniasis, or West Nile virus.
;;
;; 1. Diagnosis
;; Does the Veteran now have or has he/she ever been diagnosed with any of the
;; infectious diseases listed above?
;; ___ Yes ___ No
;;
;; If yes, indicate the infectious disease(s)/agent(s) that the Veteran now has
;; or has been diagnosed with:
;; ___ brucellosis
;; ICD code: __________ Date of diagnosis: _______________
;; ___ Campylobacter jejuni
;; ICD code: __________ Date of diagnosis: _______________
;; ___ Coxiella burnetii (Q-fever)
;; ICD code: __________ Date of diagnosis: _______________
;; ___ malaria
;; ICD code: __________ Date of diagnosis: _______________
;; ___ nontyphoid Salmonella
;; ICD code: __________ Date of diagnosis: _______________
;; ___ Shigella
;; ICD code: __________ Date of diagnosis: _______________
;; ___ visceral leishmaniasis
;; ICD code: __________ Date of diagnosis: _______________
;; ___ West Nile virus
;; ICD code: __________ Date of diagnosis: _______________
;; ___ Mycobacterium tuberculosis (TB)
;; If TB is the only diagnosis checked, do not complete the rest of this
;; Questionnaire; instead, complete the Tuberculosis Questionnaire.
;;
;; If any other disease(s) have been checked along with mycobacterium
;; tuberculosis, complete the Tuberculosis Questionnaire for all tuberculosis-
;; related conditions, and also complete this Questionnaire (Persian Gulf and
;; Afghanistan Infectious Diseases) for all other non-tuberculosis related
;; diseases checked above.
;;^TOF^
;; 2. Medical history for disease #1
;; a. Name of disease #1: _________________________
;; Describe the history (including onset and course) of the Veteran's disease #1:
;; _____________________________________________________________________________
;;
;; b. Status of disease #1:
;; ___ Active
;; ___ Inactive/treated and resolved
;;
;; c. If inactive, date disease became inactive/resolved: ______________________
;;
;; d. If inactive/resolved, are there residuals due to the disease?
;; ___ Yes ___ No
;; If yes, describe residuals: _________________________________________________
;; Also complete appropriate Questionnaire for each specific residual condition,
;; if indicated.
;;
;; 3. Medical history for disease #2
;; a. Name of disease #2: _________________________
;; Describe the history (including onset and course) of the Veteran's disease #2:
;; _____________________________________________________________________________
;;
;; b. Status of disease #2:
;; ___ Active
;; ___ Inactive/treated and resolved
;;
;; c. If inactive, date disease became inactive/resolved: ______________________
;;
;; d. If inactive/resolved, are there residuals due to the disease?
;; ___ Yes ___ No
;; If yes, describe residuals: _________________________________________________
;; Also complete appropriate Questionnaire for each specific residual condition,
;; if indicated.
;;
;; 4. Medical history for disease #3
;; a. Name of disease #3: _________________________
;; Describe the history (including onset and course) of the Veteran's disease #3:
;; _____________________________________________________________________________
;;
;; b. Status of disease #3:
;; ___ Active
;; ___ Inactive/treated and resolved
;;
;; c. If inactive, date disease became inactive/resolved: ______________________
;;
;; d. If inactive/resolved, are there residuals due to the disease?
;; ___ Yes ___ No
;; If yes, describe residuals: ______________________
;; Also complete appropriate Questionnaire for each specific residual condition,
;; if indicated.
;;^TOF^
;; 5. Additional Gulf War infectious diseases
;; If the Veteran has had any additional Gulf War infectious diseases, describe
;; using above format: _________________________________________________________
;;
;; 6. 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): __________________________________________
;;
;; 7. Diagnostic testing
;; NOTE: If the Veteran has had diagnostic testing for suspected or confirmed
;; Gulf War infectious diseases and the results are in the medical record and
;; reflect the Veteran's current status, repeat testing is not indicated.
;;
;; 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):
;; _____________________________________________________________________________
;;
;; 8. Functional impact
;; Does the Veteran's Gulf War infectious disease(s) impact his or her ability
;; to work?
;; ___ Yes ___ No
;; If yes, describe impact of each of the Veteran's Gulf War infectious
;; diseases, providing one or more examples:
;; _____________________________________________________________________________
;;
;; 9. 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[HDVBCQPG2 7255 printed Dec 13, 2024@01:47:44 Page 2
DVBCQPG2 ;;ALB-CIOFO/ECF,SBW - PERSION GULF & AFGHANISTAN INFECTION DISEASE QUESTIONNAIRE ; 4/APR/2011
+1 ;;2.7;AMIE;**166**;Apr 10, 1995;Build 6
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;;
+5 ;; NOTE: This questionnaire is intended solely for claims based on 38 CFR 3.317(c)
+6 ;; Presumptive service connection for infectious disease. Therefore, this
+7 ;; questionnaire should only be completed for Veterans who have or have had one
+8 ;; or more of the following diseases/infections of the following agents:
+9 ;; brucellosis, campylobacteriosis (Campylobacter jejuni), Q-fever (Coxiella
+10 ;; burnetii), malaria, tuberculosis (Mycobacterium tuberculosis), nontyphoid
+11 ;; Salmonella, shigellosis (Shigella), visceral leishmaniasis, or West Nile virus.
+12 ;;
+13 ;; 1. Diagnosis
+14 ;; Does the Veteran now have or has he/she ever been diagnosed with any of the
+15 ;; infectious diseases listed above?
+16 ;; ___ Yes ___ No
+17 ;;
+18 ;; If yes, indicate the infectious disease(s)/agent(s) that the Veteran now has
+19 ;; or has been diagnosed with:
+20 ;; ___ brucellosis
+21 ;; ICD code: __________ Date of diagnosis: _______________
+22 ;; ___ Campylobacter jejuni
+23 ;; ICD code: __________ Date of diagnosis: _______________
+24 ;; ___ Coxiella burnetii (Q-fever)
+25 ;; ICD code: __________ Date of diagnosis: _______________
+26 ;; ___ malaria
+27 ;; ICD code: __________ Date of diagnosis: _______________
+28 ;; ___ nontyphoid Salmonella
+29 ;; ICD code: __________ Date of diagnosis: _______________
+30 ;; ___ Shigella
+31 ;; ICD code: __________ Date of diagnosis: _______________
+32 ;; ___ visceral leishmaniasis
+33 ;; ICD code: __________ Date of diagnosis: _______________
+34 ;; ___ West Nile virus
+35 ;; ICD code: __________ Date of diagnosis: _______________
+36 ;; ___ Mycobacterium tuberculosis (TB)
+37 ;; If TB is the only diagnosis checked, do not complete the rest of this
+38 ;; Questionnaire; instead, complete the Tuberculosis Questionnaire.
+39 ;;
+40 ;; If any other disease(s) have been checked along with mycobacterium
+41 ;; tuberculosis, complete the Tuberculosis Questionnaire for all tuberculosis-
+42 ;; related conditions, and also complete this Questionnaire (Persian Gulf and
+43 ;; Afghanistan Infectious Diseases) for all other non-tuberculosis related
+44 ;; diseases checked above.
+45 ;;^TOF^
+46 ;; 2. Medical history for disease #1
+47 ;; a. Name of disease #1: _________________________
+48 ;; Describe the history (including onset and course) of the Veteran's disease #1:
+49 ;; _____________________________________________________________________________
+50 ;;
+51 ;; b. Status of disease #1:
+52 ;; ___ Active
+53 ;; ___ Inactive/treated and resolved
+54 ;;
+55 ;; c. If inactive, date disease became inactive/resolved: ______________________
+56 ;;
+57 ;; d. If inactive/resolved, are there residuals due to the disease?
+58 ;; ___ Yes ___ No
+59 ;; If yes, describe residuals: _________________________________________________
+60 ;; Also complete appropriate Questionnaire for each specific residual condition,
+61 ;; if indicated.
+62 ;;
+63 ;; 3. Medical history for disease #2
+64 ;; a. Name of disease #2: _________________________
+65 ;; Describe the history (including onset and course) of the Veteran's disease #2:
+66 ;; _____________________________________________________________________________
+67 ;;
+68 ;; b. Status of disease #2:
+69 ;; ___ Active
+70 ;; ___ Inactive/treated and resolved
+71 ;;
+72 ;; c. If inactive, date disease became inactive/resolved: ______________________
+73 ;;
+74 ;; d. If inactive/resolved, are there residuals due to the disease?
+75 ;; ___ Yes ___ No
+76 ;; If yes, describe residuals: _________________________________________________
+77 ;; Also complete appropriate Questionnaire for each specific residual condition,
+78 ;; if indicated.
+79 ;;
+80 ;; 4. Medical history for disease #3
+81 ;; a. Name of disease #3: _________________________
+82 ;; Describe the history (including onset and course) of the Veteran's disease #3:
+83 ;; _____________________________________________________________________________
+84 ;;
+85 ;; b. Status of disease #3:
+86 ;; ___ Active
+87 ;; ___ Inactive/treated and resolved
+88 ;;
+89 ;; c. If inactive, date disease became inactive/resolved: ______________________
+90 ;;
+91 ;; d. If inactive/resolved, are there residuals due to the disease?
+92 ;; ___ Yes ___ No
+93 ;; If yes, describe residuals: ______________________
+94 ;; Also complete appropriate Questionnaire for each specific residual condition,
+95 ;; if indicated.
+96 ;;^TOF^
+97 ;; 5. Additional Gulf War infectious diseases
+98 ;; If the Veteran has had any additional Gulf War infectious diseases, describe
+99 ;; using above format: _________________________________________________________
+100 ;;
+101 ;; 6. Other pertinent physical findings, complications, conditions, signs and/or
+102 ;; symptoms
+103 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+104 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+105 ;; section above?
+106 ;; ___ Yes ___ No
+107 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+108 ;; of all related scars greater than 39 square cm (6 square inches)?
+109 ;; ___ Yes ___ No
+110 ;; If yes, also complete a Scars Questionnaire.
+111 ;;
+112 ;; b. Does the Veteran have any other pertinent physical findings,
+113 ;; complications, conditions, signs or symptoms?
+114 ;; ___ Yes ___ No
+115 ;; If yes, describe (brief summary): __________________________________________
+116 ;;
+117 ;; 7. Diagnostic testing
+118 ;; NOTE: If the Veteran has had diagnostic testing for suspected or confirmed
+119 ;; Gulf War infectious diseases and the results are in the medical record and
+120 ;; reflect the Veteran's current status, repeat testing is not indicated.
+121 ;;
+122 ;; Are there any significant diagnostic test findings and/or results?
+123 ;; ___ Yes ___ No
+124 ;; If yes, provide type of test or procedure, date and results (brief summary):
+125 ;; _____________________________________________________________________________
+126 ;;
+127 ;; 8. Functional impact
+128 ;; Does the Veteran's Gulf War infectious disease(s) impact his or her ability
+129 ;; to work?
+130 ;; ___ Yes ___ No
+131 ;; If yes, describe impact of each of the Veteran's Gulf War infectious
+132 ;; diseases, providing one or more examples:
+133 ;; _____________________________________________________________________________
+134 ;;
+135 ;; 9. Remarks, if any: _________________________________________________________
+136 ;;
+137 ;; Physician signature: _____________________________________ Date: ____________
+138 ;; Physician printed name: _____________________________________________________
+139 ;; Medical license #: __________________________________________________________
+140 ;; Physician address: __________________________________________________________
+141 ;; Phone: _____________________________ FAX: _______________________________
+142 ;;
+143 ;; NOTE: VA may request additional medical information, including additional
+144 ;; examinations if necessary to complete VA's review of the Veteran's
+145 ;; application.
+146 ;;^END^
+147 QUIT
