Routine: DVBCQSD2

DVBCQSD2 ;;ALB-CIOFO/ECF,SBW - STOMACH, DUODENUM QUESTIONNAIRE ; 5/JUL/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 stomach or duodenum

 ;; conditions?

 ;; ___ Yes   ___ No

;;

 ;; If yes, select the Veteran's condition (check all that apply):

 ;;    ___ Gastric ulcer       ICD code: ______   Date of diagnosis: ____________

 ;;    ___ Duodenal ulcer      ICD code: ______   Date of diagnosis: ____________

 ;;    ___ Stenosis of the stomach

 ;;                            ICD code: ______   Date of diagnosis: ____________

 ;;    ___ Marginal (gastrojejunal) ulcer

 ;;                            ICD code: ______   Date of diagnosis: ____________

 ;;    ___ Hypertrophic gastritis

 ;;                            ICD code: ______   Date of diagnosis: ____________

 ;;    ___ Postgastrectomy syndrome

 ;;                            ICD code: ______   Date of diagnosis: ____________

 ;;    ___ Status post vagotomy with pyloroplasty

 ;;                            ICD code: ______   Date of diagnosis: ____________

 ;;    ___ Gastroenterostomy   ICD code: ______   Date of diagnosis: ____________

 ;;    ___ Peritoneal adhesions following injury or surgery of the stomach

 ;;                            ICD code: ______   Date of diagnosis: ____________

 ;;    ___ Helicobacter pylori ICD code: ______   Date of diagnosis: ____________

 ;;    ___ Other stomach or duodenal conditions:

;;

 ;; Other diagnosis #1: ____________________

 ;; ICD code: ________________________

 ;; Date of diagnosis: _______________

;;

 ;; Other diagnosis #2: ____________________

 ;; ICD code: ________________________

 ;; Date of diagnosis: _______________

;;

 ;; If there are additional diagnoses that pertain to stomach or duodenal

 ;; conditions, list using above format: ________________________________________

;;

 ;; NOTE: The diagnosis of gastric or duodenal ulcer or stenosis can be made by

 ;; upper gastrointestinal imaging series or endoscopy. The diagnosis of gastritis

 ;; requires endoscopic confirmation. If testing is of record and is consistent

 ;; with Veteran's current condition, repeat testing is not required.

;;

 ;; 2. Medical History

 ;; a. Describe the history (including onset and course) of the Veteran's stomach

 ;; or duodenum conditions (brief summary): _____________________________________

 ;; _____________________________________________________________________________

 ;;^TOF^

 ;; b. Does the Veteran's treatment plan include taking continuous medication for

 ;; the diagnosed condition?

 ;; ___ Yes   ___ No

 ;; If yes, list only those medications used for the diagnosed condition:  ______

 ;; _____________________________________________________________________________

;;

 ;; 3. Signs and symptoms

 ;; Does the Veteran have any of the following signs or symptoms due to any

 ;; stomach or duodenum conditions?

 ;; ___ Yes   ___ No

 ;; If yes, check all that apply:

 ;; ___ Recurring episodes of symptoms that are not severe

 ;;    If checked, indicate frequency of episodes of symptom recurrence per year:

 ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 ;;    If checked, indicate average duration of episodes of symptoms:

 ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

 ;; ___ Recurring episodes of severe symptoms

 ;;    If checked, indicate frequency of episodes of symptom recurrence per year:

 ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 ;;    If checked, indicate average duration of episodes of symptoms:

 ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

 ;; ___ Abdominal pain

 ;;    If checked, indicate severity and frequency (check all that apply):

 ;;    ___ Occurs less than monthly

 ;;    ___ Occurs at least monthly

 ;;    ___ Pronounced

 ;;    ___ Periodic

 ;;    ___ Continuous

 ;;    ___ Relieved by standard ulcer therapy

 ;;    ___ Only partially relieved by standard ulcer therapy

 ;;    ___ Unrelieved by standard ulcer therapy

 ;; ___ Anemia

 ;;    If checked, provide hemoglobin/hematocrit in diagnostic testing section.

 ;; ___ Weight loss

 ;;    If checked, provide baseline weight: _______ and current weight: _______

 ;;    (For VA purposes, baseline weight is the average weight for 2-year period

 ;;    preceding onset of disease)

 ;; ___ Nausea

 ;;    If checked, indicate severity:

 ;;    ___ Mild   ___ Transient   ___ Recurrent   ___ Periodic

 ;;    If checked, indicate frequency of episodes of nausea per year:

 ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 ;;    If checked, indicate average duration of episodes of nausea:

 ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

 ;;^TOF^

 ;; ___ Vomiting

 ;;    If checked, indicate severity:

 ;;    ___ Mild   ___ Transient   ___ Recurrent   ___ Periodic

 ;;    If checked, indicate frequency of episodes of vomiting per year:

 ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 ;;   If checked, indicate average duration of episodes of vomiting:

 ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

 ;; ___ Hematemesis

 ;;    If checked, indicate severity:

 ;;    ___ Mild   ___ Transient   ___ Recurrent   ___ Periodic

 ;;    If checked, indicate frequency of episodes of hematemesis per year:

 ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 ;;    If checked, indicate average duration of episodes of hematemesis:

 ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

 ;; ___ Melena

 ;;    If checked, indicate severity:

 ;;    ___ Mild   ___ Transient   ___ Recurrent   ___ Periodic

 ;;    If checked, indicate frequency of episodes of melena per year:

 ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 ;;    If checked, indicate average duration of episodes of melena:

 ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

;;

 ;; 4. Incapacitating episodes

 ;; Does the Veteran have incapacitating episodes due to signs or symptoms of any

 ;; stomach or duodenum condition?

 ;; ___ Yes   ___ No

 ;; If yes, describe incapacitating episodes: ___________________________________

 ;;    Indicate frequency of incapacitating episodes per year:

 ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 ;; Indicate average duration of incapacitating episodes:

 ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

;;

 ;; 5. Other conditions

 ;; Does the Veteran have any of the following conditions?

 ;; ___ Yes   ___ No

 ;; If yes, indicate conditions and complete appropriate sections (check all

 ;; that apply)

;;

 ;; a. ___ Hypertrophic gastritis

 ;;     If checked, indicate severity:

 ;;        ___ No symptoms or findings

 ;;        ___ Chronic, with small nodular lesions, and symptoms

 ;;        ___ Chronic, with multiple small eroded or ulcerated areas,

 ;;            and symptoms

 ;;        ___ Chronic, with severe hemorrhages, or large ulcerated or

 ;;            eroded areas

;;

 ;;        Note: If atrophic gastritis is present, state the underlying cause:

 ;;        ______________________________________________________________________

 ;;^TOF^

 ;; b. ___ Postgastrectomy syndrome

 ;;     If checked, indicate severity:

 ;;        ___ No symptoms or findings

 ;;        ___ Mild; infrequent episodes of epigastric distress with characteristic

 ;;            mild circulatory symptoms or continuous mild manifestations

 ;;        ___ Moderate; less frequent episodes of epigastric disorders with

 ;;            characteristic mild circulatory symptoms after meals but with

 ;;            diarrhea and weight loss

;;

 ;;        ___ Severe; associated with nausea, sweating, circulatory disturbance

 ;;            after meals, diarrhea, hypoglycemic symptoms and weight loss with

 ;;            malnutrition and anemia

;;

 ;; c. ___ Vagotomy with pyloroplasty or gastroenterostomy

 ;;     If checked, indicate the severity of residuals following vagotomy with

 ;;     pyloroplasty or gastroenterostomy:

 ;;        ___ No symptoms or findings

 ;;        ___ Recurrent ulcer with incomplete vagotomy

 ;;        ___ Symptoms and confirmed diagnosis of alkaline gastritis, or of

 ;;            confirmed persisting diarrhea

 ;;        ___ Demonstrably confirmative postoperative complications of stricture

 ;;            or continuing gastric retention

;;

 ;; d. ___ Peritoneal adhesions following an injury or surgical procedure of the

 ;; stomach or duodenum

 ;;     If checked, ALSO complete the Peritoneal Adhesions Questionnaire.

;;

 ;; 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 and/or symptoms related to any conditions listed in the

 ;; Diagnosis section above?

 ;; ___ Yes   ___ No

 ;; If yes, describe (brief summary): ___________________________________________

;;

 ;; 7. Diagnostic testing

 ;; NOTE: If testing has been performed and reflects Veteran's current condition,

 ;; no further testing is required for this examination report. The diagnosis of

 ;; gastric or duodenal ulcer or stenosis can be made by upper gastrointestinal

 ;; imaging series or endoscopy.

 ;;^TOF^

 ;; a. Have diagnostic imaging studies or other diagnostic procedures been

 ;; performed?

 ;; ___ Yes   ___ No

 ;; If yes, check all that apply:

 ;;     ___ Upper endoscopy    Date: ___________   Results: ______________

 ;;     ___ Upper GI radiographic studies

 ;;                            Date: ___________   Results: ______________

 ;;     ___ MRI                Date: ___________   Results: ______________

 ;;     ___ CT                 Date: ___________   Results: ______________

 ;;     ___ Biopsy, specify site: ________________________

 ;;                            Date: ___________   Results: ______________

 ;;     ___ Other, specify: ______________________________

 ;;                            Date: ___________   Results: ______________

;;

 ;; b. Has laboratory testing been performed?

 ;; ___ Yes   ___ No

 ;; If yes, check all that apply:

 ;;     ___ CBC                     Date of test: ___________

 ;;         Hemoglobin: ______      Hematocrit: _______

 ;;         White blood cell count: ______  Platelets: _____

 ;;     ___ Helicobacter pylori     Date of test: __________  Results: ____________

 ;;     ___ Other, specify: ______  Date of test: __________  Results: ____________

;;

 ;; 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):

 ;; _____________________________________________________________________________

;;

 ;; 8. Functional impact

 ;; Do any of the Veteran's stomach or duodenum conditions impact his or her

 ;; ability to work?

 ;; ___ Yes   ___ No

 ;; If yes, describe impact of each of the Veteran's stomach or duodenum

 ;; conditions, 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^

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQSD2   12529     printed  Mar 13, 2025@20:52:51                                                                                                                                                                                                   Page 2

DVBCQSD2  ;;ALB-CIOFO/ECF,SBW - STOMACH, DUODENUM QUESTIONNAIRE ; 5/JUL/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 stomach or duodenum

 +7       ;; conditions?

 +8       ;; ___ Yes   ___ No

 +9       ;;

 +10      ;; If yes, select the Veteran's condition (check all that apply):

 +11      ;;    ___ Gastric ulcer       ICD code: ______   Date of diagnosis: ____________

 +12      ;;    ___ Duodenal ulcer      ICD code: ______   Date of diagnosis: ____________

 +13      ;;    ___ Stenosis of the stomach

 +14      ;;                            ICD code: ______   Date of diagnosis: ____________

 +15      ;;    ___ Marginal (gastrojejunal) ulcer

 +16      ;;                            ICD code: ______   Date of diagnosis: ____________

 +17      ;;    ___ Hypertrophic gastritis

 +18      ;;                            ICD code: ______   Date of diagnosis: ____________

 +19      ;;    ___ Postgastrectomy syndrome

 +20      ;;                            ICD code: ______   Date of diagnosis: ____________

 +21      ;;    ___ Status post vagotomy with pyloroplasty

 +22      ;;                            ICD code: ______   Date of diagnosis: ____________

 +23      ;;    ___ Gastroenterostomy   ICD code: ______   Date of diagnosis: ____________

 +24      ;;    ___ Peritoneal adhesions following injury or surgery of the stomach

 +25      ;;                            ICD code: ______   Date of diagnosis: ____________

 +26      ;;    ___ Helicobacter pylori ICD code: ______   Date of diagnosis: ____________

 +27      ;;    ___ Other stomach or duodenal conditions:

 +28      ;;

 +29      ;; Other diagnosis #1: ____________________

 +30      ;; ICD code: ________________________

 +31      ;; Date of diagnosis: _______________

 +32      ;;

 +33      ;; Other diagnosis #2: ____________________

 +34      ;; ICD code: ________________________

 +35      ;; Date of diagnosis: _______________

 +36      ;;

 +37      ;; If there are additional diagnoses that pertain to stomach or duodenal

 +38      ;; conditions, list using above format: ________________________________________

 +39      ;;

 +40      ;; NOTE: The diagnosis of gastric or duodenal ulcer or stenosis can be made by

 +41      ;; upper gastrointestinal imaging series or endoscopy. The diagnosis of gastritis

 +42      ;; requires endoscopic confirmation. If testing is of record and is consistent

 +43      ;; with Veteran's current condition, repeat testing is not required.

 +44      ;;

 +45      ;; 2. Medical History

 +46      ;; a. Describe the history (including onset and course) of the Veteran's stomach

 +47      ;; or duodenum conditions (brief summary): _____________________________________

 +48      ;; _____________________________________________________________________________

 +49      ;;^TOF^

 +50      ;; b. Does the Veteran's treatment plan include taking continuous medication for

 +51      ;; the diagnosed condition?

 +52      ;; ___ Yes   ___ No

 +53      ;; If yes, list only those medications used for the diagnosed condition:  ______

 +54      ;; _____________________________________________________________________________

 +55      ;;

 +56      ;; 3. Signs and symptoms

 +57      ;; Does the Veteran have any of the following signs or symptoms due to any

 +58      ;; stomach or duodenum conditions?

 +59      ;; ___ Yes   ___ No

 +60      ;; If yes, check all that apply:

 +61      ;; ___ Recurring episodes of symptoms that are not severe

 +62      ;;    If checked, indicate frequency of episodes of symptom recurrence per year:

 +63      ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 +64      ;;    If checked, indicate average duration of episodes of symptoms:

 +65      ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

 +66      ;; ___ Recurring episodes of severe symptoms

 +67      ;;    If checked, indicate frequency of episodes of symptom recurrence per year:

 +68      ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 +69      ;;    If checked, indicate average duration of episodes of symptoms:

 +70      ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

 +71      ;; ___ Abdominal pain

 +72      ;;    If checked, indicate severity and frequency (check all that apply):

 +73      ;;    ___ Occurs less than monthly

 +74      ;;    ___ Occurs at least monthly

 +75      ;;    ___ Pronounced

 +76      ;;    ___ Periodic

 +77      ;;    ___ Continuous

 +78      ;;    ___ Relieved by standard ulcer therapy

 +79      ;;    ___ Only partially relieved by standard ulcer therapy

 +80      ;;    ___ Unrelieved by standard ulcer therapy

 +81      ;; ___ Anemia

 +82      ;;    If checked, provide hemoglobin/hematocrit in diagnostic testing section.

 +83      ;; ___ Weight loss

 +84      ;;    If checked, provide baseline weight: _______ and current weight: _______

 +85      ;;    (For VA purposes, baseline weight is the average weight for 2-year period

 +86      ;;    preceding onset of disease)

 +87      ;; ___ Nausea

 +88      ;;    If checked, indicate severity:

 +89      ;;    ___ Mild   ___ Transient   ___ Recurrent   ___ Periodic

 +90      ;;    If checked, indicate frequency of episodes of nausea per year:

 +91      ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 +92      ;;    If checked, indicate average duration of episodes of nausea:

 +93      ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

 +94      ;;^TOF^

 +95      ;; ___ Vomiting

 +96      ;;    If checked, indicate severity:

 +97      ;;    ___ Mild   ___ Transient   ___ Recurrent   ___ Periodic

 +98      ;;    If checked, indicate frequency of episodes of vomiting per year:

 +99      ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 +100     ;;   If checked, indicate average duration of episodes of vomiting:

 +101     ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

 +102     ;; ___ Hematemesis

 +103     ;;    If checked, indicate severity:

 +104     ;;    ___ Mild   ___ Transient   ___ Recurrent   ___ Periodic

 +105     ;;    If checked, indicate frequency of episodes of hematemesis per year:

 +106     ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 +107     ;;    If checked, indicate average duration of episodes of hematemesis:

 +108     ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

 +109     ;; ___ Melena

 +110     ;;    If checked, indicate severity:

 +111     ;;    ___ Mild   ___ Transient   ___ Recurrent   ___ Periodic

 +112     ;;    If checked, indicate frequency of episodes of melena per year:

 +113     ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 +114     ;;    If checked, indicate average duration of episodes of melena:

 +115     ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

 +116     ;;

 +117     ;; 4. Incapacitating episodes

 +118     ;; Does the Veteran have incapacitating episodes due to signs or symptoms of any

 +119     ;; stomach or duodenum condition?

 +120     ;; ___ Yes   ___ No

 +121     ;; If yes, describe incapacitating episodes: ___________________________________

 +122     ;;    Indicate frequency of incapacitating episodes per year:

 +123     ;;    ___ 1   ___ 2   ___ 3   ___ 4 or more

 +124     ;; Indicate average duration of incapacitating episodes:

 +125     ;;    ___ Less than 1 day   ___ 1-9 days   ___ 10 days or more

 +126     ;;

 +127     ;; 5. Other conditions

 +128     ;; Does the Veteran have any of the following conditions?

 +129     ;; ___ Yes   ___ No

 +130     ;; If yes, indicate conditions and complete appropriate sections (check all

 +131     ;; that apply)

 +132     ;;

 +133     ;; a. ___ Hypertrophic gastritis

 +134     ;;     If checked, indicate severity:

 +135     ;;        ___ No symptoms or findings

 +136     ;;        ___ Chronic, with small nodular lesions, and symptoms

 +137     ;;        ___ Chronic, with multiple small eroded or ulcerated areas,

 +138     ;;            and symptoms

 +139     ;;        ___ Chronic, with severe hemorrhages, or large ulcerated or

 +140     ;;            eroded areas

 +141     ;;

 +142     ;;        Note: If atrophic gastritis is present, state the underlying cause:

 +143     ;;        ______________________________________________________________________

 +144     ;;^TOF^

 +145     ;; b. ___ Postgastrectomy syndrome

 +146     ;;     If checked, indicate severity:

 +147     ;;        ___ No symptoms or findings

 +148     ;;        ___ Mild; infrequent episodes of epigastric distress with characteristic

 +149     ;;            mild circulatory symptoms or continuous mild manifestations

 +150     ;;        ___ Moderate; less frequent episodes of epigastric disorders with

 +151     ;;            characteristic mild circulatory symptoms after meals but with

 +152     ;;            diarrhea and weight loss

 +153     ;;

 +154     ;;        ___ Severe; associated with nausea, sweating, circulatory disturbance

 +155     ;;            after meals, diarrhea, hypoglycemic symptoms and weight loss with

 +156     ;;            malnutrition and anemia

 +157     ;;

 +158     ;; c. ___ Vagotomy with pyloroplasty or gastroenterostomy

 +159     ;;     If checked, indicate the severity of residuals following vagotomy with

 +160     ;;     pyloroplasty or gastroenterostomy:

 +161     ;;        ___ No symptoms or findings

 +162     ;;        ___ Recurrent ulcer with incomplete vagotomy

 +163     ;;        ___ Symptoms and confirmed diagnosis of alkaline gastritis, or of

 +164     ;;            confirmed persisting diarrhea

 +165     ;;        ___ Demonstrably confirmative postoperative complications of stricture

 +166     ;;            or continuing gastric retention

 +167     ;;

 +168     ;; d. ___ Peritoneal adhesions following an injury or surgical procedure of the

 +169     ;; stomach or duodenum

 +170     ;;     If checked, ALSO complete the Peritoneal Adhesions Questionnaire.

 +171     ;;

 +172     ;; 6. Other pertinent physical findings, complications, conditions, signs and/or

 +173     ;; symptoms

 +174     ;; a. Does the Veteran have any scars (surgical or otherwise) related to any

 +175     ;; conditions or to the treatment of any conditions listed in the Diagnosis

 +176     ;; section above?

 +177     ;; ___ Yes   ___ No

 +178     ;; If yes, are any of the scars painful and/or unstable, or is the total area of

 +179     ;; all related scars greater than 39 square cm (6 square inches)?

 +180     ;;     ___ Yes   ___ No

 +181     ;;        If yes, also complete a Scars Questionnaire.

 +182     ;;

 +183     ;; b.  Does the Veteran have any other pertinent physical findings, complications,

 +184     ;; conditions, signs and/or symptoms related to any conditions listed in the

 +185     ;; Diagnosis section above?

 +186     ;; ___ Yes   ___ No

 +187     ;; If yes, describe (brief summary): ___________________________________________

 +188     ;;

 +189     ;; 7. Diagnostic testing

 +190     ;; NOTE: If testing has been performed and reflects Veteran's current condition,

 +191     ;; no further testing is required for this examination report. The diagnosis of

 +192     ;; gastric or duodenal ulcer or stenosis can be made by upper gastrointestinal

 +193     ;; imaging series or endoscopy.

 +194     ;;^TOF^

 +195     ;; a. Have diagnostic imaging studies or other diagnostic procedures been

 +196     ;; performed?

 +197     ;; ___ Yes   ___ No

 +198     ;; If yes, check all that apply:

 +199     ;;     ___ Upper endoscopy    Date: ___________   Results: ______________

 +200     ;;     ___ Upper GI radiographic studies

 +201     ;;                            Date: ___________   Results: ______________

 +202     ;;     ___ MRI                Date: ___________   Results: ______________

 +203     ;;     ___ CT                 Date: ___________   Results: ______________

 +204     ;;     ___ Biopsy, specify site: ________________________

 +205     ;;                            Date: ___________   Results: ______________

 +206     ;;     ___ Other, specify: ______________________________

 +207     ;;                            Date: ___________   Results: ______________

 +208     ;;

 +209     ;; b. Has laboratory testing been performed?

 +210     ;; ___ Yes   ___ No

 +211     ;; If yes, check all that apply:

 +212     ;;     ___ CBC                     Date of test: ___________

 +213     ;;         Hemoglobin: ______      Hematocrit: _______

 +214     ;;         White blood cell count: ______  Platelets: _____

 +215     ;;     ___ Helicobacter pylori     Date of test: __________  Results: ____________

 +216     ;;     ___ Other, specify: ______  Date of test: __________  Results: ____________

 +217     ;;

 +218     ;; c. Are there any other significant diagnostic test findings and/or results?

 +219     ;; ___ Yes   ___ No

 +220     ;; If yes, provide type of test or procedure, date and results (brief summary):

 +221     ;; _____________________________________________________________________________

 +222     ;;

 +223     ;; 8. Functional impact

 +224     ;; Do any of the Veteran's stomach or duodenum conditions impact his or her

 +225     ;; ability to work?

 +226     ;; ___ Yes   ___ No

 +227     ;; If yes, describe impact of each of the Veteran's stomach or duodenum

 +228     ;; conditions, providing one or more examples: _________________________________

 +229     ;; _____________________________________________________________________________

 +230     ;;

 +231     ;; 9. Remarks, if any: _________________________________________________________

 +232     ;;

 +233     ;; Physician signature: _____________________________________ Date: ____________

 +234     ;;

 +235     ;; Physician printed name: __________________________________

 +236     ;;

 +237     ;; Medical license #: __________________

 +238     ;;

 +239     ;; Physician address: __________________________________________________________

 +240     ;;

 +241     ;; Phone: _______________________ Fax: _______________________

 +242     ;;

 +243     ;; NOTE: VA may request additional medical information, including additional

 +244     ;; examinations if necessary to complete VA's review of the Veteran's application.

 +245     ;;^END^

 +246      QUIT

DVBCQSD2.m