DVBCQSC3 ;;ALB-CIOFO/ECF - SCARS DISFIGUREMENT QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
;
TXT ;
;;
;; SECTION II: Scars or other disfigurement of the head, face or neck
;;
;; 1. Medical history
;;
;; a. Describe the history (including cause/origin and course) of the
;; Veteran's scar(s) or other disfigurement of the head, face, or neck (brief
;; summary): __________________________________________________________________
;;
;; b. Are any of the scars or of the head, face, or neck painful?
;; ___ Yes ___ No
;; If yes, specify number of painful scars:
;; __ 1 __ 2 __ 3 __ 4 __ 5 or more
;; Describe the pain (if there are multiple painful scars, be sure to
;; adequately identify which scars are painful): ___________________________
;;
;; c. Are any of the scars or of the head, face, or neck
;; unstable, with frequent loss of covering of skin over the scar?
;; ___ Yes ___ No
;; If yes, specify number of unstable scars:
;; __ 1 __ 2 __ 3 __ 4 __ 5 or more
;; Describe the loss of covering of skin over the scar (if there are
;; multiple unstable scars, be sure to adequately identify which scars are
;; unstable):
;; _________________________________________________________________________
;;^TOF^
;; d. Are any of the scars or of the head, face or neck
;; BOTH painful and unstable?
;; ___ Yes ___ No
;; If yes, specify number of scars that are both painful and unstable:
;; __ 1 __ 2 __ 3 __ 4 __ 5 or more
;; Describe location of these scars: _______________________________________
;;
;; e. Are any of the scars of the head, face, or neck due to burns?
;; ___ Yes ___ No
;; If yes, identify each burn scar and state depth of original burn:
;; Burn Scar #1: _____________________
;; ___ Full thickness or sub-dermal
;; ___ Deep partial thickness
;; ___ Less than deep partial thickness
;; Burn Scar #1: _____________________
;; ___ Full thickness or sub-dermal
;; ___ Deep partial thickness
;; ___ Less than deep partial thickness
;;
;; If there are additional burn scars of the head, face, or neck, list using
;; the above format: __________________________________________________________
;;
;; 2. Physical exam for scars or disfigurement of the head, face and neck
;;
;; 2-1. Details of scar or disfigurement for the head, face, and neck
;;
;; a. Identify each scar or other disfigurement and provide measurements:
;;
;; Scar/Disfigurement #1
;; Indicate type of impairment: ___Scar ___ Disfigurement
;; Location of scar/disfigurement #1: ____________________________________
;; Length and width (at widest part) of scar/disfigurement #1: ___x___ cm
;;
;; Scar/Disfigurement #2
;; Indicate type of impairment: ___Scar ___ Disfigurement
;; Location of scar/disfigurement #2: ____________________________________
;; Length and width (at widest part) of scar/disfigurement #2: ___x___ cm
;;
;; Scar/Disfigurement #3
;; Indicate type of impairment: ___Scar ___ Disfigurement)
;; Location of scar/disfigurement #3: ____________________________________
;; Length and width (at widest part) of scar/disfigurement #3: ___x___ cm
;;
;; Scar/Disfigurement #4
;; Indicate type of impairment: ___Scar ___ Disfigurement
;; Location of scar/disfigurement #4: ____________________________________
;; Length and width (at widest part) of scar/disfigurement #4: ___x___ cm
;;^TOF^
;; Scar/Disfigurement #5
;; Indicate type of impairment: ___Scar ___ Disfigurement
;; Location of scar/disfigurement #5: ____________________________________
;; Length and width (at widest part) of scar/disfigurement #5: ___x___ cm
;;
;; If additional scars or disfigurement, list using same format:
;; ____________________________________________________________________________
;;
;; b. Is there elevation, depression, adherence to underlying tissue, or
;; missing underlying soft tissue?
;; ___ Yes ___ No
;; If yes, check all that apply:
;;
;; ___ Surface contour elevated on palpation
;; If checked, identify each affected scar/disfigurement:
;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
;; ___ Scar/Disfigurement #5 ___ Other: ______________
;;
;; ___ Surface contour depressed on palpation
;; If checked, identify each affected scar/disfigurement:
;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
;; ___ Scar/Disfigurement #5 ___ Other: ______________
;;
;; ___ Scar adherent to underlying tissue
;; If checked, identify each affected scar/disfigurement:
;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
;; ___ Scar/Disfigurement #5 ___ Other: ______________
;;
;; ___ Underlying soft tissue missing
;; If checked, identify each affected scar/disfigurement:
;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
;; ___ Scar/Disfigurement #5 ___ Other: ______________
;;^TOF^
;; c. Is there abnormal pigmentation or texture of the head, face, or neck?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Hypopigmentation
;; If checked, identify each affected scar/disfigurement:
;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
;; ___ Scar/Disfigurement #5 ___ Other: ______________
;;
;; ___ Hyperpigmentation
;; If checked, identify each affected scar/disfigurement:
;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
;; ___ Scar/Disfigurement #5 ___ Other: ______________
;;
;; ___ Induration and inflexibility
;; If checked, identify each affected scar/disfigurement:
;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
;; ___ Scar/Disfigurement #5 ___ Other: ______________
;;
;; ___ Abnormal texture
;; If checked, identify each affected scar/disfigurement:
;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
;; ___ Scar/Disfigurement #5 ___ Other: ______________
;; Describe type of abnormal texture (for example, irregular,
;; atrophic, shiny or scaly):
;; ____________________________________________________________________
;;
;; 2-2. Summary of scars or other disfigurement of the head, face and neck
;;
;; Provide approximate combined total area in centimeters squared for each
;; characteristic of disfigurement:
;;
;; a. Approximate total area of head, face and neck with hypo- or
;; hyperpigmented areas: _____ cm2
;;
;; b. Approximate total area of head, face and neck with abnormal texture:
;; _____ cm2
;;
;; c. Approximate total area of head, face and neck with missing underlying
;; soft tissue: _____ cm2
;;
;; d. Approximate total area of head, face and neck that is indurated and
;; inflexible: _____ cm2
;;^TOF^
;; 2-3. Distortion of facial features and tissue loss for the head, face and
;; neck
;;
;; Is there gross distortion or asymmetry of facial features or visible or
;; palpable tissue loss?
;; ___ Yes ___ No
;; If yes, indicate features affected (check all that apply):
;; ___ Nose ___ Chin ___ Forehead ___ Cheeks ___ Lips
;; ___ Eyes (including eyelids)
;; If checked, specify:
;; ___ Tissue loss/distortion of eyelid Side: ___ Right ___ Left
;; ___ Tissue loss/distortion of eye Side: ___ Right ___ Left
;; ___ Anatomical loss of eye Side: ___ Right ___ Left
;; ___ Ears (auricles)
;; If checked, specify:
;; ___ Complete loss of auricle Side: ___ Right ___ Left
;; ___ Deformity of auricle, with loss of
;; less than one-third the substance Side: ___ Right ___ Left
;; ___ Deformity of auricle, with loss of
;; one-third or more of the substance Side: ___ Right ___ Left
;;
;; For all checked features, provide brief description of the tissue loss,
;; gross distortion and/or asymmetry of facial features: ______________________
;;
;; SECTION III: Miscellaneous
;;
;; Complete this section for all scars or disfigurements, regardless of
;; location.
;;
;; 1. Limitation of function/other conditions
;;
;; a. Do any of the scars (regardless of location) or disfigurement of the
;; head, face, or neck result in limitation of function?
;; ___ Yes ___ No
;; If yes, indicate which scars (regardless of location) or disfigurement of
;; the head, face, or neck are causing the limitation and
;; describe the specific limitations: _________________________________________
;;
;; b. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs and/or symptoms (such as muscle or nerve
;; damage) associated with any scar (regardless of location) or disfigurement
;; of the head, face, or neck?
;; ___ Yes ___ No
;; If yes, describe (brief summary): __________________________________________
;;
;; ____________________________________________________________________________
;;^TOF^
;; 2. Color photographs
;;
;; Provide color photographs, if possible, for any disfiguring conditions of
;; the head, face and/or neck.
;; ___ Photographs not indicated ___ Photographs provided
;; ___ Photographs not available
;;
;; 3. Functional impact
;;
;; Does the Veteran's scar(s) (regardless of location) or disfigurement of the
;; head, face, or neck impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe impact of the Veteran's scar(s) (regardless of location)
;; or disfigurement of the head, face, or neck, providing one or more examples:
;;
;; ____________________________________________________________________________
;;
;; 4. Remarks, if any: ________________________________________________________
;;
;; Physician signature: ____________________________________ Date: ____________
;;
;; Physician printed name: _________________________________ Phone: ___________
;;
;; Medical license #: ______________________________________ Fax: _____________
;;
;; Physician address: _________________________________________________________
;;
;; 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[HDVBCQSC3 11406 printed Sep 15, 2024@21:12:21 Page 2
DVBCQSC3 ;;ALB-CIOFO/ECF - SCARS DISFIGUREMENT QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;;
+2 ;; SECTION II: Scars or other disfigurement of the head, face or neck
+3 ;;
+4 ;; 1. Medical history
+5 ;;
+6 ;; a. Describe the history (including cause/origin and course) of the
+7 ;; Veteran's scar(s) or other disfigurement of the head, face, or neck (brief
+8 ;; summary): __________________________________________________________________
+9 ;;
+10 ;; b. Are any of the scars or of the head, face, or neck painful?
+11 ;; ___ Yes ___ No
+12 ;; If yes, specify number of painful scars:
+13 ;; __ 1 __ 2 __ 3 __ 4 __ 5 or more
+14 ;; Describe the pain (if there are multiple painful scars, be sure to
+15 ;; adequately identify which scars are painful): ___________________________
+16 ;;
+17 ;; c. Are any of the scars or of the head, face, or neck
+18 ;; unstable, with frequent loss of covering of skin over the scar?
+19 ;; ___ Yes ___ No
+20 ;; If yes, specify number of unstable scars:
+21 ;; __ 1 __ 2 __ 3 __ 4 __ 5 or more
+22 ;; Describe the loss of covering of skin over the scar (if there are
+23 ;; multiple unstable scars, be sure to adequately identify which scars are
+24 ;; unstable):
+25 ;; _________________________________________________________________________
+26 ;;^TOF^
+27 ;; d. Are any of the scars or of the head, face or neck
+28 ;; BOTH painful and unstable?
+29 ;; ___ Yes ___ No
+30 ;; If yes, specify number of scars that are both painful and unstable:
+31 ;; __ 1 __ 2 __ 3 __ 4 __ 5 or more
+32 ;; Describe location of these scars: _______________________________________
+33 ;;
+34 ;; e. Are any of the scars of the head, face, or neck due to burns?
+35 ;; ___ Yes ___ No
+36 ;; If yes, identify each burn scar and state depth of original burn:
+37 ;; Burn Scar #1: _____________________
+38 ;; ___ Full thickness or sub-dermal
+39 ;; ___ Deep partial thickness
+40 ;; ___ Less than deep partial thickness
+41 ;; Burn Scar #1: _____________________
+42 ;; ___ Full thickness or sub-dermal
+43 ;; ___ Deep partial thickness
+44 ;; ___ Less than deep partial thickness
+45 ;;
+46 ;; If there are additional burn scars of the head, face, or neck, list using
+47 ;; the above format: __________________________________________________________
+48 ;;
+49 ;; 2. Physical exam for scars or disfigurement of the head, face and neck
+50 ;;
+51 ;; 2-1. Details of scar or disfigurement for the head, face, and neck
+52 ;;
+53 ;; a. Identify each scar or other disfigurement and provide measurements:
+54 ;;
+55 ;; Scar/Disfigurement #1
+56 ;; Indicate type of impairment: ___Scar ___ Disfigurement
+57 ;; Location of scar/disfigurement #1: ____________________________________
+58 ;; Length and width (at widest part) of scar/disfigurement #1: ___x___ cm
+59 ;;
+60 ;; Scar/Disfigurement #2
+61 ;; Indicate type of impairment: ___Scar ___ Disfigurement
+62 ;; Location of scar/disfigurement #2: ____________________________________
+63 ;; Length and width (at widest part) of scar/disfigurement #2: ___x___ cm
+64 ;;
+65 ;; Scar/Disfigurement #3
+66 ;; Indicate type of impairment: ___Scar ___ Disfigurement)
+67 ;; Location of scar/disfigurement #3: ____________________________________
+68 ;; Length and width (at widest part) of scar/disfigurement #3: ___x___ cm
+69 ;;
+70 ;; Scar/Disfigurement #4
+71 ;; Indicate type of impairment: ___Scar ___ Disfigurement
+72 ;; Location of scar/disfigurement #4: ____________________________________
+73 ;; Length and width (at widest part) of scar/disfigurement #4: ___x___ cm
+74 ;;^TOF^
+75 ;; Scar/Disfigurement #5
+76 ;; Indicate type of impairment: ___Scar ___ Disfigurement
+77 ;; Location of scar/disfigurement #5: ____________________________________
+78 ;; Length and width (at widest part) of scar/disfigurement #5: ___x___ cm
+79 ;;
+80 ;; If additional scars or disfigurement, list using same format:
+81 ;; ____________________________________________________________________________
+82 ;;
+83 ;; b. Is there elevation, depression, adherence to underlying tissue, or
+84 ;; missing underlying soft tissue?
+85 ;; ___ Yes ___ No
+86 ;; If yes, check all that apply:
+87 ;;
+88 ;; ___ Surface contour elevated on palpation
+89 ;; If checked, identify each affected scar/disfigurement:
+90 ;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
+91 ;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
+92 ;; ___ Scar/Disfigurement #5 ___ Other: ______________
+93 ;;
+94 ;; ___ Surface contour depressed on palpation
+95 ;; If checked, identify each affected scar/disfigurement:
+96 ;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
+97 ;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
+98 ;; ___ Scar/Disfigurement #5 ___ Other: ______________
+99 ;;
+100 ;; ___ Scar adherent to underlying tissue
+101 ;; If checked, identify each affected scar/disfigurement:
+102 ;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
+103 ;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
+104 ;; ___ Scar/Disfigurement #5 ___ Other: ______________
+105 ;;
+106 ;; ___ Underlying soft tissue missing
+107 ;; If checked, identify each affected scar/disfigurement:
+108 ;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
+109 ;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
+110 ;; ___ Scar/Disfigurement #5 ___ Other: ______________
+111 ;;^TOF^
+112 ;; c. Is there abnormal pigmentation or texture of the head, face, or neck?
+113 ;; ___ Yes ___ No
+114 ;; If yes, check all that apply:
+115 ;; ___ Hypopigmentation
+116 ;; If checked, identify each affected scar/disfigurement:
+117 ;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
+118 ;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
+119 ;; ___ Scar/Disfigurement #5 ___ Other: ______________
+120 ;;
+121 ;; ___ Hyperpigmentation
+122 ;; If checked, identify each affected scar/disfigurement:
+123 ;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
+124 ;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
+125 ;; ___ Scar/Disfigurement #5 ___ Other: ______________
+126 ;;
+127 ;; ___ Induration and inflexibility
+128 ;; If checked, identify each affected scar/disfigurement:
+129 ;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
+130 ;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
+131 ;; ___ Scar/Disfigurement #5 ___ Other: ______________
+132 ;;
+133 ;; ___ Abnormal texture
+134 ;; If checked, identify each affected scar/disfigurement:
+135 ;; ___ Scar/Disfigurement #1 ___ Scar/Disfigurement #2
+136 ;; ___ Scar/Disfigurement #3 ___ Scar/Disfigurement #4
+137 ;; ___ Scar/Disfigurement #5 ___ Other: ______________
+138 ;; Describe type of abnormal texture (for example, irregular,
+139 ;; atrophic, shiny or scaly):
+140 ;; ____________________________________________________________________
+141 ;;
+142 ;; 2-2. Summary of scars or other disfigurement of the head, face and neck
+143 ;;
+144 ;; Provide approximate combined total area in centimeters squared for each
+145 ;; characteristic of disfigurement:
+146 ;;
+147 ;; a. Approximate total area of head, face and neck with hypo- or
+148 ;; hyperpigmented areas: _____ cm2
+149 ;;
+150 ;; b. Approximate total area of head, face and neck with abnormal texture:
+151 ;; _____ cm2
+152 ;;
+153 ;; c. Approximate total area of head, face and neck with missing underlying
+154 ;; soft tissue: _____ cm2
+155 ;;
+156 ;; d. Approximate total area of head, face and neck that is indurated and
+157 ;; inflexible: _____ cm2
+158 ;;^TOF^
+159 ;; 2-3. Distortion of facial features and tissue loss for the head, face and
+160 ;; neck
+161 ;;
+162 ;; Is there gross distortion or asymmetry of facial features or visible or
+163 ;; palpable tissue loss?
+164 ;; ___ Yes ___ No
+165 ;; If yes, indicate features affected (check all that apply):
+166 ;; ___ Nose ___ Chin ___ Forehead ___ Cheeks ___ Lips
+167 ;; ___ Eyes (including eyelids)
+168 ;; If checked, specify:
+169 ;; ___ Tissue loss/distortion of eyelid Side: ___ Right ___ Left
+170 ;; ___ Tissue loss/distortion of eye Side: ___ Right ___ Left
+171 ;; ___ Anatomical loss of eye Side: ___ Right ___ Left
+172 ;; ___ Ears (auricles)
+173 ;; If checked, specify:
+174 ;; ___ Complete loss of auricle Side: ___ Right ___ Left
+175 ;; ___ Deformity of auricle, with loss of
+176 ;; less than one-third the substance Side: ___ Right ___ Left
+177 ;; ___ Deformity of auricle, with loss of
+178 ;; one-third or more of the substance Side: ___ Right ___ Left
+179 ;;
+180 ;; For all checked features, provide brief description of the tissue loss,
+181 ;; gross distortion and/or asymmetry of facial features: ______________________
+182 ;;
+183 ;; SECTION III: Miscellaneous
+184 ;;
+185 ;; Complete this section for all scars or disfigurements, regardless of
+186 ;; location.
+187 ;;
+188 ;; 1. Limitation of function/other conditions
+189 ;;
+190 ;; a. Do any of the scars (regardless of location) or disfigurement of the
+191 ;; head, face, or neck result in limitation of function?
+192 ;; ___ Yes ___ No
+193 ;; If yes, indicate which scars (regardless of location) or disfigurement of
+194 ;; the head, face, or neck are causing the limitation and
+195 ;; describe the specific limitations: _________________________________________
+196 ;;
+197 ;; b. Does the Veteran have any other pertinent physical findings,
+198 ;; complications, conditions, signs and/or symptoms (such as muscle or nerve
+199 ;; damage) associated with any scar (regardless of location) or disfigurement
+200 ;; of the head, face, or neck?
+201 ;; ___ Yes ___ No
+202 ;; If yes, describe (brief summary): __________________________________________
+203 ;;
+204 ;; ____________________________________________________________________________
+205 ;;^TOF^
+206 ;; 2. Color photographs
+207 ;;
+208 ;; Provide color photographs, if possible, for any disfiguring conditions of
+209 ;; the head, face and/or neck.
+210 ;; ___ Photographs not indicated ___ Photographs provided
+211 ;; ___ Photographs not available
+212 ;;
+213 ;; 3. Functional impact
+214 ;;
+215 ;; Does the Veteran's scar(s) (regardless of location) or disfigurement of the
+216 ;; head, face, or neck impact his or her ability to work?
+217 ;; ___ Yes ___ No
+218 ;; If yes, describe impact of the Veteran's scar(s) (regardless of location)
+219 ;; or disfigurement of the head, face, or neck, providing one or more examples:
+220 ;;
+221 ;; ____________________________________________________________________________
+222 ;;
+223 ;; 4. Remarks, if any: ________________________________________________________
+224 ;;
+225 ;; Physician signature: ____________________________________ Date: ____________
+226 ;;
+227 ;; Physician printed name: _________________________________ Phone: ___________
+228 ;;
+229 ;; Medical license #: ______________________________________ Fax: _____________
+230 ;;
+231 ;; Physician address: _________________________________________________________
+232 ;;
+233 ;; NOTE: VA may request additional medical information, including additional
+234 ;; examinations if necessary to complete VA's review of the Veteran's
+235 ;; application.
+236 ;;^END^
+237 QUIT
