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
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQSK2 13995 printed Nov 22, 2024@16:58:22 Page 2
DVBCQSK2 ;;ALB-CIOFO/ECF - SKIN DISEASES QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+2 ;; (VA) for disability benefits. VA will consider the information you
+3 ;; provide on this questionnaire as part of their evaluation in processing
+4 ;; the Veteran's claim.
+5 ;;
+6 ;; 1. Diagnosis:
+7 ;;
+8 ;; Does the Veteran now have or has he/she ever had a skin condition?
+9 ;; ___ Yes ___ No
+10 ;;
+11 ;; If yes, provide only diagnoses that pertain to skin conditions.
+12 ;; Indicate the category of skin condition, and then provide specific
+13 ;; diagnosis in that category (check all that apply):
+14 ;; ___ Dermatitis or eczema
+15 ;; Diagnosis: ______________________ ICD code: __________
+16 ;; Date of diagnosis: ______________
+17 ;; ___ Infectious skin conditions (including bacterial, fungal,
+18 ;; viral, treponemal and parasitic skin conditions)
+19 ;; Diagnosis: ______________________ ICD code: __________
+20 ;; Date of diagnosis: ______________
+21 ;; ___ Bullous disorders
+22 ;; Diagnosis: ______________________ ICD code: __________
+23 ;; Date of diagnosis: ______________
+24 ;; ___ Psoriasis ICD code: __________
+25 ;; Date of diagnosis: ______________
+26 ;; ___ Exfoliative dermatitis (erythroderma) ICD code: __________
+27 ;; Date of diagnosis: ______________
+28 ;; ___ Cutaneous manifestations of collagen-vascular diseases
+29 ;; Diagnosis: ______________________ ICD code: __________
+30 ;; Date of diagnosis: ______________
+31 ;; ___ Papulosquamous skin disorders
+32 ;; Diagnosis: ______________________ ICD code: __________
+33 ;; Date of diagnosis: ______________
+34 ;; ___ Vitiligo
+35 ;; Diagnosis: ______________________ ICD code: __________
+36 ;; Date of diagnosis: ______________
+37 ;; ___ Keratinization skin disorders
+38 ;; Diagnosis: ______________________ ICD code: __________
+39 ;; Date of diagnosis: ______________
+40 ;; ___ Urticaria
+41 ;; Diagnosis: ______________________ ICD code: __________
+42 ;; Date of diagnosis: ______________
+43 ;; ___ Primary cutaneous vasculitis
+44 ;; ___ Erythema multiforme ICD code: __________
+45 ;; Date of diagnosis: ______________
+46 ;; ___ Acne ICD code: __________
+47 ;; Date of diagnosis: ______________
+48 ;; ___ Chloracne ICD code: __________
+49 ;; Date of diagnosis: ______________
+50 ;;^TOF^
+51 ;; ___ Alopecia ICD code: __________
+52 ;; Date of diagnosis: ______________
+53 ;; ___ Hyperhidrosis ICD code: __________
+54 ;; Date of diagnosis: ______________
+55 ;; ___ Tumors and neoplasms of the skin, including malignant melanoma
+56 ;; Diagnosis: ______________________ ICD code: __________
+57 ;; Date of diagnosis: ______________
+58 ;; ___ Other skin condition
+59 ;; Other diagnosis #1: ________________________________________________
+60 ;; ICD code: _________________ Date of diagnosis: ______________
+61 ;; Other diagnosis #2: ________________________________________________
+62 ;; ICD code: _________________ Date of diagnosis: ______________
+63 ;; Other diagnosis #3: ________________________________________________
+64 ;; ICD code: __________ Date of diagnosis: ______________
+65 ;;
+66 ;; If there are additional diagnoses that pertain to the skin conditions, list
+67 ;; using above format:
+68 ;; ____________________________________________________________________________
+69 ;;
+70 ;; 2. Medical History
+71 ;;
+72 ;; a. Describe the history (including onset and course) of the Veteran's skin
+73 ;; conditions (brief summary): ________________________________________________
+74 ;;
+75 ;; b. Do any of the Veteran's skin conditions cause scarring or disfigurement
+76 ;; of the head, face or neck?
+77 ;; ___ Yes ___ No
+78 ;; If yes, indicate skin condition and describe scarring and/or disfigurement:
+79 ;; ____________________________________________________________________________
+80 ;; Also complete the Scars Questionnaire if appropriate.
+81 ;;
+82 ;; c. Does the Veteran have any benign or malignant skin neoplasms (including
+83 ;; malignant melanoma)?
+84 ;; ___ Yes ___ No
+85 ;; If yes, also complete the Tumors and Neoplasms Questionnaire.
+86 ;;
+87 ;; d. Does the Veteran have any systemic manifestations due to any skin
+88 ;; diseases (such as fever, weight loss or hypoproteinemia associated with skin
+89 ;; conditions such as erythroderma)?
+90 ;; ___ Yes ___ No
+91 ;; If yes, describe: __________________________________________________________
+92 ;; Also complete additional Questionnaires if appropriate.
+93 ;;^TOF^
+94 ;; 3. Treatment
+95 ;;
+96 ;; a. Has the Veteran been treated with oral or topical medications in the past
+97 ;; 12 months for any skin condition?
+98 ;; ___ Yes ___ No
+99 ;; If yes, check all that apply:
+100 ;;
+101 ;; ___ Systemic corticosteroids or other immunosuppressive medications
+102 ;; If checked, list medication(s): _________________________________________
+103 ;; Specify condition medication used for: _________________________________
+104 ;; Total duration of medication use in past 12 months:
+105 ;; ___ < 6 weeks ___ 6 weeks or more, but not constant
+106 ;; ___ Constant/near-constant
+107 ;;
+108 ;; ___ Antihistamines
+109 ;; If checked, list medication(s): _________________________________________
+110 ;; Specify condition medication used for: _________________________________
+111 ;; Total duration of medication use in past 12 months:
+112 ;; ___ < 6 weeks ___ 6 weeks or more, but not constant
+113 ;; ___ Constant/near-constant
+114 ;;
+115 ;; ___ Immunosuppressive retinoids
+116 ;; If checked, list medication(s): _________________________________________
+117 ;; Specify condition medication used for: _________________________________
+118 ;; Total duration of medication use in past 12 months:
+119 ;; ___ < 6 weeks ___ 6 weeks or more, but not constant
+120 ;; ___ Constant/near-constant
+121 ;;
+122 ;; ___ Sympathomimetics
+123 ;; If checked, list medication(s): _________________________________________
+124 ;; Specify condition medication used for: _________________________________
+125 ;; Total duration of medication use in past 12 months:
+126 ;; ___ < 6 weeks ___ 6 weeks or more, but not constant
+127 ;; ___ Constant/near-constant
+128 ;;
+129 ;; ___ Other oral medications
+130 ;; If checked, list medication(s): _________________________________________
+131 ;; Specify condition medication used for: _________________________________
+132 ;; Total duration of medication use in past 12 months:
+133 ;; ___ < 6 weeks ___ 6 weeks or more, but not constant
+134 ;; ___ Constant/near-constant
+135 ;;
+136 ;; ___ Topical corticosteroids
+137 ;; If checked, list medication(s): ___________________________________________
+138 ;; Specify condition medication used for: ____________________________________
+139 ;; Total duration of medication use in past 12 months:
+140 ;; ___ < 6 weeks ___ 6 weeks or more, but not constant
+141 ;; ___ Constant/near-constant
+142 ;;^TOF^
+143 ;; ___ Other topical medications
+144 ;; If checked, list medication(s): _________________________________________
+145 ;; Specify condition medication used for: _________________________________
+146 ;; Total duration of medication use in past 12 months:
+147 ;; ___ < 6 weeks ___ 6 weeks or more, but not constant
+148 ;; ___ Constant/near-constant
+149 ;;
+150 ;; NOTE: If a medication is used for more than one condition, provide names of
+151 ;; all conditions, name of medication used for each condition, and frequency
+152 ;; of use for each condition: _________________________________________________
+153 ;;
+154 ;; b. Has the Veteran had any treatments or procedures other than systemic or
+155 ;; topical medications in the past 12 months for exfoliative dermatitis or
+156 ;; papulosquamous disorders?
+157 ;; ___ Yes ___ No
+158 ;;
+159 ;; If yes, check all that apply:
+160 ;; ___ PUVA (photo-chemotherapy with psoralen and ultraviolet A) treatment
+161 ;; If checked, specify condition treated: ______________________________
+162 ;; Date of most recent treatment: _______________
+163 ;; Total duration of treatment in past 12 months:
+164 ;; ___ < 6 weeks ___ 6 weeks or more, but not constant
+165 ;; ___ Constant/near-constant
+166 ;;
+167 ;; ___ UVB (ultraviolet B phototherapy) treatment
+168 ;; If checked, specify condition treated: ______________________________
+169 ;; Date of most recent treatment: _______________
+170 ;; Total duration of treatment in past 12 months:
+171 ;; ___ < 6 weeks ___ 6 weeks or more, but not constant
+172 ;; ___ Constant/near-constant
+173 ;;
+174 ;; ___ Electron beam therapy
+175 ;; If checked, specify condition treated: ______________________________
+176 ;; Date of most recent treatment: _______________
+177 ;; Total duration of treatment in past 12 months:
+178 ;; ___ < 6 weeks ___ 6 weeks or more, but not constant
+179 ;; ___ Constant/near-constant
+180 ;;
+181 ;; ___ Intensive light therapy
+182 ;; If checked, specify condition treated: ______________________________
+183 ;; Date of most recent treatment: _______________
+184 ;; Total duration of treatment in past 12 months:
+185 ;; ___ < 6 weeks ___ 6 weeks or more, but not constant
+186 ;; ___ Constant/near-constant
+187 ;;^TOF^
+188 ;; ___ Other treatment
+189 ;; Specify treatment: __________________________________________________
+190 ;; Specify condition treated: __________________________________________
+191 ;; Date of most recent treatment: _______________
+192 ;; Total duration of treatment in past 12 months:
+193 ;; ___ < 6 weeks ___ 6 weeks or more, but not constant
+194 ;; ___ Constant/near-constant
+195 ;;
+196 ;; 4. Debilitating and non-debilitating episodes
+197 ;;
+198 ;; a. Has the Veteran had any debilitating episodes in the past 12 months due
+199 ;; to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic
+200 ;; epidermal necrolysis?
+201 ;; ___ Yes ___ No
+202 ;;
+203 ;; If yes, specify condition causing debilitating episodes:
+204 ;; ___ urticaria ___ primary cutaneous vasculitis
+205 ;; ___ erythema multiforme ___ toxic epidermal necrolysis
+206 ;; Describe debilitating episodes (brief summary): _________________________
+207 ;; Number of debilitating episodes in past 12 months:
+208 ;; ___ 1 ___ 2 ___ 3 ___ 4 or more
+209 ;; Characteristics of debilitating episodes
+210 ;; ___ Occurred despite ongoing immunosuppressive therapy
+211 ;; ___ Required treatment with intermittent systemic immunosuppressive
+212 ;; therapy
+213 ;; ___ Responded to treatment with antihistamines or sympathomimetics
+214 ;;
+215 ;; b. Has the Veteran had any non-debilitating episodes of urticaria, primary
+216 ;; cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in
+217 ;; the past 12 months?
+218 ;; ___ Yes ___ No
+219 ;;
+220 ;; If yes, specify condition causing non-debilitating episodes:
+221 ;; ___ urticaria ___ primary cutaneous vasculitis
+222 ;; ___ erythema multiforme ___ toxic epidermal necrolysis
+223 ;; Describe episodes (brief summary): ____________________
+224 ;; Number of non-debilitating episodes in past 12 months:
+225 ;; ___ 1 ___ 2 ___ 3 ___ 4 or more
+226 ;; Characteristics of non-debilitating episodes
+227 ;; ___ Occurred despite ongoing immunosuppressive therapy
+228 ;; ___ Required treatment with intermittent systemic immunosuppressive
+229 ;; therapy
+230 ;; ___ Responded to treatment with antihistamines or sympathomimetics
+231 ;;
+232 ;; NOTE: If the Veteran's debilitating and/or non-debilitating episodes are due
+233 ;; to more than one condition, provide names of all conditions, indicating
+234 ;; severity and frequency of episodes for each condition: _____________________
+235 ;;^TOF^
+236 ;; 5. Physical exam
+237 ;;
+238 ;; a. Indicate the Veteran's visible skin conditions; indicate the approximate
+239 ;; total body area and approximate total EXPOSED body area (face, neck and
+240 ;; hands) affected on current examination (check all that apply):
+241 ;;
+242 ;; ___ Dermatitis
+243 ;; Total body area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+244 ;; EXPOSED area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+245 ;;
+246 ;; ___ Eczema
+247 ;; Total body area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+248 ;; EXPOSED area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+249 ;;
+250 ;; __ Bullous disorder
+251 ;; Total body area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+252 ;; EXPOSED area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+253 ;;
+254 ;; __ Psoriasis
+255 ;; Total body area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+256 ;; EXPOSED area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+257 ;;
+258 ;; ___ Infections of the skin
+259 ;; Total body area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+260 ;; EXPOSED area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+261 ;;
+262 ;; ___ Cutaneous manifestations of collagen-vascular disease
+263 ;; Total body area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+264 ;; EXPOSED area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+265 ;;
+266 ;; ___ Papulosquamous disorder
+267 ;; Total body area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+268 ;; EXPOSED area ___None ___<5% ___5% to <20% ___20% to 40% ___>40%
+269 ;;
+270 ;; ___ The Veteran does not have any of the above listed visible skin
+271 ;; conditions
+272 ;;
+273 ;; b. For each skin condition, give specific diagnosis and describe appearance
+274 ;; and location: ______________________________________________________________
+275 QUIT
