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Routine: DVBCQSK2

DVBCQSK2.m

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DVBCQSK2 ;;ALB-CIOFO/ECF -  SKIN DISEASES QUESTIONNAIRE ; 6/15/2011
 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
 ;
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 a skin condition?
 ;; ___ Yes    ___ No
 ;;
 ;; If yes, provide only diagnoses that pertain to skin conditions. 
 ;; Indicate the category of skin condition, and then provide specific
 ;; diagnosis in that category (check all that apply):
 ;; ___ Dermatitis or eczema
 ;;     Diagnosis: ______________________     ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Infectious skin conditions (including bacterial, fungal,
 ;;     viral, treponemal and parasitic skin conditions)
 ;;     Diagnosis: ______________________     ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Bullous disorders
 ;;     Diagnosis: ______________________     ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Psoriasis                             ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Exfoliative dermatitis (erythroderma) ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Cutaneous manifestations of collagen-vascular diseases
 ;;     Diagnosis: ______________________     ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Papulosquamous skin disorders
 ;;     Diagnosis: ______________________     ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Vitiligo
 ;;     Diagnosis: ______________________     ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Keratinization skin disorders
 ;;     Diagnosis: ______________________     ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Urticaria
 ;;     Diagnosis: ______________________     ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Primary cutaneous vasculitis
 ;; ___ Erythema multiforme                   ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Acne                                  ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Chloracne                             ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;;^TOF^
 ;; ___ Alopecia                              ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Hyperhidrosis                         ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Tumors and neoplasms of the skin, including malignant melanoma
 ;;     Diagnosis: ______________________     ICD code:  __________
 ;;     Date of diagnosis: ______________
 ;; ___ Other skin condition
 ;;     Other diagnosis #1: ________________________________________________
 ;;     ICD code:  _________________       Date of diagnosis: ______________
 ;;     Other diagnosis #2: ________________________________________________
 ;;     ICD code:  _________________       Date of diagnosis: ______________
 ;;     Other diagnosis #3: ________________________________________________
 ;;     ICD code:  __________              Date of diagnosis: ______________
 ;;
 ;; If there are additional diagnoses that pertain to the skin conditions, list
 ;; using above format:
 ;; ____________________________________________________________________________
 ;;
 ;; 2. Medical History
 ;;
 ;; a. Describe the history (including onset and course) of the Veteran's skin
 ;; conditions (brief summary): ________________________________________________
 ;;
 ;; b. Do any of the Veteran's skin conditions cause scarring or disfigurement
 ;; of the head, face or neck?
 ;; ___ Yes    ___ No
 ;; If yes, indicate skin condition and describe scarring and/or disfigurement:
 ;; ____________________________________________________________________________
 ;; Also complete the Scars Questionnaire if appropriate.
 ;;
 ;; c. Does the Veteran have any benign or malignant skin neoplasms (including
 ;; malignant melanoma)?
 ;; ___ Yes    ___ No
 ;; If yes, also complete the Tumors and Neoplasms Questionnaire.
 ;;
 ;; d. Does the Veteran have any systemic manifestations due to any skin
 ;; diseases (such as fever, weight loss or hypoproteinemia associated with skin
 ;; conditions such as erythroderma)?
 ;; ___ Yes    ___ No
 ;; If yes, describe: __________________________________________________________
 ;; Also complete additional Questionnaires if appropriate.
 ;;^TOF^
 ;; 3. Treatment
 ;;
 ;; a. Has the Veteran been treated with oral or topical medications in the past
 ;; 12 months for any skin condition?
 ;; ___ Yes    ___ No
 ;; If yes, check all that apply:
 ;;
 ;; ___ Systemic corticosteroids or other immunosuppressive medications
 ;;    If checked, list medication(s): _________________________________________
 ;;     Specify condition medication used for: _________________________________
 ;;    Total duration of medication use in past 12 months:
 ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
 ;;    ___  Constant/near-constant
 ;;
 ;; ___ Antihistamines
 ;;    If checked, list medication(s): _________________________________________
 ;;     Specify condition medication used for: _________________________________ 
 ;;    Total duration of medication use in past 12 months:
 ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
 ;;    ___  Constant/near-constant
 ;;
 ;;  ___  Immunosuppressive retinoids
 ;;    If checked, list medication(s): _________________________________________
 ;;     Specify condition medication used for: _________________________________ 
 ;;    Total duration of medication use in past 12 months:
 ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
 ;;    ___  Constant/near-constant
 ;;
 ;; ___ Sympathomimetics
 ;;    If checked, list medication(s): _________________________________________
 ;;     Specify condition medication used for: _________________________________ 
 ;;    Total duration of medication use in past 12 months:
 ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
 ;;    ___  Constant/near-constant
 ;;
 ;; ___ Other oral medications
 ;;    If checked, list medication(s): _________________________________________
 ;;     Specify condition medication used for: _________________________________
 ;;    Total duration of medication use in past 12 months:
 ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
 ;;    ___  Constant/near-constant
 ;;
 ;; ___ Topical corticosteroids
 ;;  If checked, list medication(s): ___________________________________________
 ;;  Specify condition medication used for: ____________________________________
 ;;    Total duration of medication use in past 12 months:
 ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
 ;;    ___  Constant/near-constant
 ;;^TOF^
 ;; ___ Other topical medications
 ;;    If checked, list medication(s): _________________________________________
 ;;     Specify condition medication used for: _________________________________
 ;;    Total duration of medication use in past 12 months:
 ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
 ;;    ___  Constant/near-constant
 ;;
 ;; NOTE: If a medication is used for more than one condition, provide names of
 ;; all conditions, name of medication used for each condition, and frequency
 ;; of use for each condition: _________________________________________________
 ;;
 ;; b. Has the Veteran had any treatments or procedures other than systemic or
 ;; topical medications in the past 12 months for exfoliative dermatitis or
 ;; papulosquamous disorders?
 ;; ___ Yes    ___ No
 ;;
 ;; If yes, check all that apply:
 ;;    ___ PUVA (photo-chemotherapy with psoralen and ultraviolet A) treatment
 ;;        If checked, specify condition treated: ______________________________
 ;;        Date of most recent treatment: _______________
 ;;        Total duration of treatment in past 12 months: 
 ;;           ___  < 6 weeks    ___  6 weeks or more, but not constant
 ;;           ___  Constant/near-constant
 ;;
 ;;    ___ UVB (ultraviolet B phototherapy) treatment
 ;;        If checked, specify condition treated: ______________________________
 ;;        Date of most recent treatment: _______________
 ;;        Total duration of treatment in past 12 months:
 ;;        ___  < 6 weeks    ___  6 weeks or more, but not constant
 ;;        ___  Constant/near-constant
 ;;
 ;;    ___ Electron beam therapy
 ;;        If checked, specify condition treated: ______________________________
 ;;        Date of most recent treatment: _______________
 ;;        Total duration of treatment in past 12 months:
 ;;        ___  < 6 weeks    ___  6 weeks or more, but not constant
 ;;        ___  Constant/near-constant
 ;;
 ;;    ___ Intensive light therapy
 ;;        If checked, specify condition treated: ______________________________
 ;;        Date of most recent treatment: _______________
 ;;        Total duration of treatment in past 12 months:
 ;;        ___  < 6 weeks    ___  6 weeks or more, but not constant
 ;;        ___  Constant/near-constant
 ;;^TOF^
 ;;    ___ Other treatment
 ;;        Specify treatment: __________________________________________________
 ;;        Specify condition treated: __________________________________________
 ;;        Date of most recent treatment: _______________
 ;;        Total duration of treatment in past 12 months: 
 ;;        ___  < 6 weeks    ___  6 weeks or more, but not constant
 ;;        ___  Constant/near-constant
 ;;
 ;; 4. Debilitating and non-debilitating episodes
 ;;
 ;; a. Has the Veteran had any debilitating episodes in the past 12 months due
 ;; to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic
 ;; epidermal necrolysis?
 ;; ___ Yes    ___ No
 ;;
 ;; If yes, specify condition causing debilitating episodes:
 ;; ___ urticaria             ___ primary cutaneous vasculitis
 ;; ___ erythema multiforme   ___ toxic epidermal necrolysis
 ;;    Describe debilitating episodes (brief summary): _________________________
 ;;    Number of debilitating episodes in past 12 months:
 ;;       ___  1    ___  2    ___  3   ___  4 or more
 ;;    Characteristics of debilitating episodes
 ;;      ___  Occurred despite ongoing immunosuppressive therapy
 ;;      ___  Required treatment with intermittent systemic immunosuppressive
 ;;           therapy
 ;;      ___  Responded to treatment with antihistamines or sympathomimetics
 ;;
 ;; b. Has the Veteran had any non-debilitating episodes of urticaria, primary
 ;; cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in
 ;; the past 12 months?
 ;; ___ Yes    ___ No
 ;;
 ;; If yes, specify condition causing non-debilitating episodes:
 ;; ___ urticaria             ___ primary cutaneous vasculitis
 ;; ___ erythema multiforme   ___ toxic epidermal necrolysis
 ;; Describe episodes (brief summary): ____________________
 ;;    Number of non-debilitating episodes in past 12 months:
 ;;       ___  1    ___  2    ___  3   ___  4 or more
 ;;    Characteristics of non-debilitating episodes
 ;;       ___  Occurred despite ongoing immunosuppressive therapy
 ;;       ___  Required treatment with intermittent systemic immunosuppressive
 ;;            therapy
 ;;       ___  Responded to treatment with antihistamines or sympathomimetics
 ;;       
 ;; NOTE: If the Veteran's debilitating and/or non-debilitating episodes are due
 ;; to more than one condition, provide names of all conditions, indicating
 ;; severity and frequency of episodes for each condition: _____________________
 ;;^TOF^
 ;; 5. Physical exam
 ;;
 ;; a. Indicate the Veteran's visible skin conditions; indicate the approximate
 ;; total body area and approximate total EXPOSED body area (face, neck and
 ;; hands) affected on current examination (check all that apply):
 ;;
 ;; ___ Dermatitis
 ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;
 ;; ___ Eczema
 ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;
 ;; __ Bullous disorder
 ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;
 ;; __ Psoriasis
 ;; Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;; EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;
 ;; ___ Infections of the skin
 ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;
 ;; ___ Cutaneous manifestations of collagen-vascular disease
 ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;
 ;; ___ Papulosquamous disorder
 ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
 ;;
 ;; ___ The Veteran does not have any of the above listed visible skin
 ;;     conditions
 ;;
 ;; b. For each skin condition, give specific diagnosis and describe appearance
 ;; and location: ______________________________________________________________
 Q