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Routine: DVBCQSD2

DVBCQSD2.m

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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