DVBCQRA2 ;;ALB-CIOFO/ECF,SBW - RECTUM AND ANUS Questionaire; 6/JUlY/2011
;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
;
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/she ever had any condition of the rectum
;; or anus?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to rectum or anus conditions.
;; If yes, select the Veteran's condition (check all that apply):
;; ___ Internal or external hemorrhoids
;; ICD code: ______ Date of diagnosis: __________
;; ___ Anal/perianal fistula
;; ICD code: ______ Date of diagnosis: __________
;; ___ Rectal stricture ICD code: ______ Date of diagnosis: __________
;; ___ Impairment of rectal sphincter control
;; ICD code: ______ Date of diagnosis: __________
;; ___ Rectal prolapse ICD code: ______ Date of diagnosis: __________
;; ___ Pruritus ani ICD code: ______ Date of diagnosis: __________
;; ___ Other, specify below:
;;
;; Other diagnosis #1: _______________________
;; ICD code: ___________________________
;; Date of diagnosis: _______________
;;
;; Other diagnosis #2: _______________________
;; ICD code: ___________________________
;; Date of diagnosis: _______________
;;
;; If there are additional diagnoses that pertain to rectum or anus conditions,
;; list using above format: ____________________________________________________
;;
;; 2. Medical History
;; a. Describe the history (including onset and course) of the Veteran's rectum
;; or anus conditions (brief summary): _________________________________________
;;
;; b. Does the Veteran's treatment plan include taking continuous medication for
;; the diagnosed conditions?
;; ___ Yes ___ No
;; If yes, list only those medications used for the diagnosed conditions:
;; _____________________________________________________________________________
;;
;; 3. Signs and Symptoms
;; Does the Veteran have any findings, signs or symptoms attributable to any of
;; the diagnoses in Section 1?
;; ___ Yes ___ No
;; If yes, specify the conditions below and complete the appropriate sections.
;;^TOF^
;; a. ___ Internal or external hemorrhoids
;; If checked, indicate severity (check all that apply):
;; ___ Mild or moderate
;; If checked, describe: ___________________
;; ___ Large or thrombotic, irreducible, with excessive redundant tissue,
;; evidencing frequent recurrences
;; ___ With persistent bleeding
;; ___ With secondary anemia
;; If checked, provide hemoglobin/hematocrit in Diagnostic testing
;; section.
;; ___ With fissures
;; ___ Other, describe: ________________________
;;
;; b. ___ Anal/perianal fistula
;; If checked, indicate severity (check all that apply):
;; ___ Slight impairment of sphincter control, without leakage
;; If checked, describe: ___________________
;; ___ Leakage necessitates wearing of pad
;; ___ Constant slight leakage
;; ___ Occasional moderate leakage
;; ___ Occasional involuntary bowel movements
;; ___ Extensive leakage
;; ___ Fairly frequent involuntary bowel movements
;; ___ Complete loss of sphincter control
;; ___ Other, describe: ________________________
;;
;; c. ___ Rectal stricture
;; If checked, indicate severity (check all that apply):
;; ___ Moderate reduction of lumen
;; ___ Great reduction of lumen
;; ___ Moderate constant leakage
;; ___ Extensive leakage
;; ___ Requiring colostomy (which is present)
;; ___ Other, describe: ________________________
;;
;; d. ___ Impairment of rectal sphincter control
;; If checked, indicate severity (check all that apply):
;; ___ Slight impairment of sphincter control, without leakage
;; If checked, describe: ___________________
;; ___ Leakage necessitates wearing of pad
;; ___ Constant slight leakage
;; ___ Occasional moderate leakage
;; ___ Occasional involuntary bowel movements
;; ___ Extensive leakage
;; ___ Fairly frequent involuntary bowel movements
;; ___ Complete loss of sphincter control
;; ___ Other, describe: _________________________
;;^TOF^
;; e. ___ Rectal prolapse
;; If checked, indicate severity (check all that apply):
;; ___ Mild with constant slight or occasional moderate leakage
;; ___ Moderate, persistent or frequently recurring
;; ___ Severe (or complete), persistent
;; ___ Other, describe: __________________________
;;
;; f. ___ Pruritus ani
;; If checked, indicate underlying condition and describe: ____________________
;; If appropriate, complete Questionnaire for underlying condition, such
;; as the Skin Questionnaire.
;;
;; 4. Exam
;; Provide results of examination of rectal/anal area: (check all that apply)
;; ___ No exam performed for this condition; provide reason: _____________
;; ___ Normal; no external hemorrhoids, anal fissures or other abnormalities
;; ___ No external hemorrhoids; skin tags only
;; ___ Small or moderate external hemorrhoids
;; ___ Large external hemorrhoids
;; ___ Thrombotic external hemorrhoids
;; ___ Reducible external hemorrhoids
;; ___ Irreducible external hemorrhoids
;; ___ Excessive redundant tissue
;; ___ Anal fissure(s)
;; If checked, describe: ___________________
;; ___ Other, describe: ________________________
;;
;; 5. 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 and/or symptoms related to any conditions listed in the
;; Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): ___________________________________________
;;^TOF^
;; 6. Diagnostic testing
;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has
;; been performed and reflects Veteran's current condition, no further testing
;; is required for this examination report.
;;
;; a. Has laboratory testing been performed?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ CBC (if anemia due to any intestinal condition is suspected or present)
;; Date of test: ___________
;; Hemoglobin: ______ Hematocrit: _______
;; White blood cell count: ______ Platelets: _____
;; ___ Other, specify: ______
;; Date of test: ___________ Results: ______________
;;
;; b. Have imaging studies or diagnostic procedures been performed and are the
;; results available?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ___________________________________________________ _________________________
;;
;; c. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; _____________________________________________________________________________
;;
;; 7. Functional impact
;; Does the Veteran's rectum or anus condition impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's rectum or anus conditions,
;; providing one or more examples: _____________________________________________
;;
;; 8. 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[HDVBCQRA2 9105 printed Apr 09, 2024@20:58:43 Page 2
DVBCQRA2 ;;ALB-CIOFO/ECF,SBW - RECTUM AND ANUS Questionaire; 6/JUlY/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+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 ;; 1. Diagnosis
+6 ;; Does the Veteran now have or has he/she ever had any condition of the rectum
+7 ;; or anus?
+8 ;; ___ Yes ___ No
+9 ;;
+10 ;; If yes, provide only diagnoses that pertain to rectum or anus conditions.
+11 ;; If yes, select the Veteran's condition (check all that apply):
+12 ;; ___ Internal or external hemorrhoids
+13 ;; ICD code: ______ Date of diagnosis: __________
+14 ;; ___ Anal/perianal fistula
+15 ;; ICD code: ______ Date of diagnosis: __________
+16 ;; ___ Rectal stricture ICD code: ______ Date of diagnosis: __________
+17 ;; ___ Impairment of rectal sphincter control
+18 ;; ICD code: ______ Date of diagnosis: __________
+19 ;; ___ Rectal prolapse ICD code: ______ Date of diagnosis: __________
+20 ;; ___ Pruritus ani ICD code: ______ Date of diagnosis: __________
+21 ;; ___ Other, specify below:
+22 ;;
+23 ;; Other diagnosis #1: _______________________
+24 ;; ICD code: ___________________________
+25 ;; Date of diagnosis: _______________
+26 ;;
+27 ;; Other diagnosis #2: _______________________
+28 ;; ICD code: ___________________________
+29 ;; Date of diagnosis: _______________
+30 ;;
+31 ;; If there are additional diagnoses that pertain to rectum or anus conditions,
+32 ;; list using above format: ____________________________________________________
+33 ;;
+34 ;; 2. Medical History
+35 ;; a. Describe the history (including onset and course) of the Veteran's rectum
+36 ;; or anus conditions (brief summary): _________________________________________
+37 ;;
+38 ;; b. Does the Veteran's treatment plan include taking continuous medication for
+39 ;; the diagnosed conditions?
+40 ;; ___ Yes ___ No
+41 ;; If yes, list only those medications used for the diagnosed conditions:
+42 ;; _____________________________________________________________________________
+43 ;;
+44 ;; 3. Signs and Symptoms
+45 ;; Does the Veteran have any findings, signs or symptoms attributable to any of
+46 ;; the diagnoses in Section 1?
+47 ;; ___ Yes ___ No
+48 ;; If yes, specify the conditions below and complete the appropriate sections.
+49 ;;^TOF^
+50 ;; a. ___ Internal or external hemorrhoids
+51 ;; If checked, indicate severity (check all that apply):
+52 ;; ___ Mild or moderate
+53 ;; If checked, describe: ___________________
+54 ;; ___ Large or thrombotic, irreducible, with excessive redundant tissue,
+55 ;; evidencing frequent recurrences
+56 ;; ___ With persistent bleeding
+57 ;; ___ With secondary anemia
+58 ;; If checked, provide hemoglobin/hematocrit in Diagnostic testing
+59 ;; section.
+60 ;; ___ With fissures
+61 ;; ___ Other, describe: ________________________
+62 ;;
+63 ;; b. ___ Anal/perianal fistula
+64 ;; If checked, indicate severity (check all that apply):
+65 ;; ___ Slight impairment of sphincter control, without leakage
+66 ;; If checked, describe: ___________________
+67 ;; ___ Leakage necessitates wearing of pad
+68 ;; ___ Constant slight leakage
+69 ;; ___ Occasional moderate leakage
+70 ;; ___ Occasional involuntary bowel movements
+71 ;; ___ Extensive leakage
+72 ;; ___ Fairly frequent involuntary bowel movements
+73 ;; ___ Complete loss of sphincter control
+74 ;; ___ Other, describe: ________________________
+75 ;;
+76 ;; c. ___ Rectal stricture
+77 ;; If checked, indicate severity (check all that apply):
+78 ;; ___ Moderate reduction of lumen
+79 ;; ___ Great reduction of lumen
+80 ;; ___ Moderate constant leakage
+81 ;; ___ Extensive leakage
+82 ;; ___ Requiring colostomy (which is present)
+83 ;; ___ Other, describe: ________________________
+84 ;;
+85 ;; d. ___ Impairment of rectal sphincter control
+86 ;; If checked, indicate severity (check all that apply):
+87 ;; ___ Slight impairment of sphincter control, without leakage
+88 ;; If checked, describe: ___________________
+89 ;; ___ Leakage necessitates wearing of pad
+90 ;; ___ Constant slight leakage
+91 ;; ___ Occasional moderate leakage
+92 ;; ___ Occasional involuntary bowel movements
+93 ;; ___ Extensive leakage
+94 ;; ___ Fairly frequent involuntary bowel movements
+95 ;; ___ Complete loss of sphincter control
+96 ;; ___ Other, describe: _________________________
+97 ;;^TOF^
+98 ;; e. ___ Rectal prolapse
+99 ;; If checked, indicate severity (check all that apply):
+100 ;; ___ Mild with constant slight or occasional moderate leakage
+101 ;; ___ Moderate, persistent or frequently recurring
+102 ;; ___ Severe (or complete), persistent
+103 ;; ___ Other, describe: __________________________
+104 ;;
+105 ;; f. ___ Pruritus ani
+106 ;; If checked, indicate underlying condition and describe: ____________________
+107 ;; If appropriate, complete Questionnaire for underlying condition, such
+108 ;; as the Skin Questionnaire.
+109 ;;
+110 ;; 4. Exam
+111 ;; Provide results of examination of rectal/anal area: (check all that apply)
+112 ;; ___ No exam performed for this condition; provide reason: _____________
+113 ;; ___ Normal; no external hemorrhoids, anal fissures or other abnormalities
+114 ;; ___ No external hemorrhoids; skin tags only
+115 ;; ___ Small or moderate external hemorrhoids
+116 ;; ___ Large external hemorrhoids
+117 ;; ___ Thrombotic external hemorrhoids
+118 ;; ___ Reducible external hemorrhoids
+119 ;; ___ Irreducible external hemorrhoids
+120 ;; ___ Excessive redundant tissue
+121 ;; ___ Anal fissure(s)
+122 ;; If checked, describe: ___________________
+123 ;; ___ Other, describe: ________________________
+124 ;;
+125 ;; 5. Other pertinent physical findings, complications, conditions, signs and/or
+126 ;; symptoms
+127 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+128 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+129 ;; section above?
+130 ;; ___ Yes ___ No
+131 ;; If yes, are any of the scars painful and/or unstable, or is the total area of
+132 ;; all related scars greater than 39 square cm (6 square inches)?
+133 ;; ___ Yes ___ No
+134 ;; If yes, also complete a Scars Questionnaire.
+135 ;;
+136 ;; b. Does the Veteran have any other pertinent physical findings, complications,
+137 ;; conditions, signs and/or symptoms related to any conditions listed in the
+138 ;; Diagnosis section above?
+139 ;; ___ Yes ___ No
+140 ;; If yes, describe (brief summary): ___________________________________________
+141 ;;^TOF^
+142 ;; 6. Diagnostic testing
+143 ;; NOTE: If imaging studies, diagnostic procedures or laboratory testing has
+144 ;; been performed and reflects Veteran's current condition, no further testing
+145 ;; is required for this examination report.
+146 ;;
+147 ;; a. Has laboratory testing been performed?
+148 ;; ___ Yes ___ No
+149 ;; If yes, check all that apply:
+150 ;; ___ CBC (if anemia due to any intestinal condition is suspected or present)
+151 ;; Date of test: ___________
+152 ;; Hemoglobin: ______ Hematocrit: _______
+153 ;; White blood cell count: ______ Platelets: _____
+154 ;; ___ Other, specify: ______
+155 ;; Date of test: ___________ Results: ______________
+156 ;;
+157 ;; b. Have imaging studies or diagnostic procedures been performed and are the
+158 ;; results available?
+159 ;; ___ Yes ___ No
+160 ;; If yes, provide type of test or procedure, date and results (brief summary):
+161 ;; ___________________________________________________ _________________________
+162 ;;
+163 ;; c. Are there any other significant diagnostic test findings and/or results?
+164 ;; ___ Yes ___ No
+165 ;; If yes, provide type of test or procedure, date and results (brief summary):
+166 ;; _____________________________________________________________________________
+167 ;;
+168 ;; 7. Functional impact
+169 ;; Does the Veteran's rectum or anus condition impact his or her ability to work?
+170 ;; ___ Yes ___ No
+171 ;; If yes, describe the impact of each of the Veteran's rectum or anus conditions,
+172 ;; providing one or more examples: _____________________________________________
+173 ;;
+174 ;; 8. Remarks, if any: _________________________________________________________
+175 ;;
+176 ;; Physician signature: _______________________________________ Date: _________
+177 ;;
+178 ;; Physician printed name: _______________________________________
+179 ;;
+180 ;; Medical license #: _____________
+181 ;;
+182 ;; Physician address: ____________________________________________
+183 ;;
+184 ;; Phone: __________________________ Fax: ________________________
+185 ;;
+186 ;; NOTE: VA may request additional medical information, including additional
+187 ;; examinations if necessary to complete VA's review of the Veteran's application.
+188 ;;^END^
+189 QUIT
