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^
 Q
 
--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQSD2   12529     printed  Sep 23, 2025@19:24:11                                                                                                                                                                                                   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