Home   Package List   Routine Alphabetical List   Global Alphabetical List   FileMan Files List   FileMan Sub-Files List   Package Component Lists   Package-Namespace Mapping  
Routine: DVBCQSK3

DVBCQSK3.m

Go to the documentation of this file. 
  1. DVBCQSK3 ;;ALB-CIOFO/ECF -  SKIN DISEASES QUESTIONNAIRE ; 6/15/2011
  1.  ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
  1.  ;
  1. TXT ;
  1.  ;;^TOF^
  1.  ;; 6. Specific Skin Conditions
  1.  ;;
  1.  ;; Indicate the Veteran's specific skin conditions and complete all applicable
  1.  ;; subsequent questions (check all that apply):
  1.  ;;
  1.  ;; ___ Acne or Chloracne
  1.  ;; If checked, indicate severity and location (check all that apply):
  1.  ;;    ___ Superficial acne (comedones, papules, pustules, superficial cysts)
  1.  ;;        of any extent
  1.  ;;    ___ Deep acne (deep inflamed nodules and pus-filled cysts)
  1.  ;;    ___ Affects less than 40 % of face and neck
  1.  ;;    ___ Affects 40% or more of face and neck
  1.  ;;    ___ Affects body areas other than face and neck
  1.  ;;
  1.  ;; ___ Vitiligo
  1.  ;; If checked, indicate areas affected by vitiligo:
  1.  ;;    ___ Exposed areas affected
  1.  ;;    ___ No exposed areas affected
  1.  ;;
  1.  ;; ___ Scarring alopecia
  1.  ;; If checked, indicate percent of scalp affected:
  1.  ;;    ___ <20%     ___ 20 to 40%    ___ >40%
  1.  ;;
  1.  ;; ___ Alopecia areata
  1.  ;; If checked, indicate amount of hair loss:
  1.  ;;    ___ Hair loss limited to scalp and face   ___ Loss of all body hair
  1.  ;;    ___ Other, describe: ___________________________________________________
  1.  ;;
  1.  ;; ___ Hyperhidrosis
  1.  ;; If checked, indicate severity:
  1.  ;;    ___ Able to handle paper or tools after treatment
  1.  ;;    ___ Unresponsive to treatment; unable to handle paper or tools
  1.  ;;
  1.  ;; ___ Veteran does not have any of the specific skin conditions listed above
  1.  ;;
  1.  ;; 7. Tumors and neoplasms
  1.  ;;
  1.  ;; a. Does the Veteran have a benign or malignant neoplasm or metastases
  1.  ;; related to any of the diagnoses in the Diagnosis section?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, complete the following:
  1.  ;;
  1.  ;; b. Is the neoplasm
  1.  ;; ___ Benign   ___ Malignant
  1.  ;;^TOF^
  1.  ;; c. Has the Veteran completed treatment or is the Veteran currently
  1.  ;; undergoing treatment for a benign or malignant neoplasm or metastases?
  1.  ;; ___  Yes   ___  No; watchful waiting
  1.  ;; If yes, indicate type of treatment the Veteran is currently undergoing or
  1.  ;; has completed (check all that apply):
  1.  ;; ___ Treatment completed; currently in watchful waiting status
  1.  ;; ___ Surgery
  1.  ;;     If checked, describe: __________________________________________________
  1.  ;;     Date(s) of surgery: _____________________
  1.  ;; ___ Radiation therapy
  1.  ;;     Date of most recent treatment: ___________
  1.  ;;     Date of completion of treatment or anticipated date of completion: _____
  1.  ;; ___ Antineoplastic chemotherapy
  1.  ;;     Date of most recent treatment: ___________
  1.  ;;     Date of completion of treatment or anticipated date of completion: _____ 
  1.  ;; ___ Other therapeutic procedure
  1.  ;;     If checked, describe procedure: ________________________________________
  1.  ;;     Date of most recent procedure: __________
  1.  ;; ___ Other therapeutic treatment
  1.  ;;     If checked, describe treatment: ________________________________________
  1.  ;;     Date of completion of treatment or anticipated date of completion:______
  1.  ;;
  1.  ;; d. Does the Veteran currently have any residual conditions or complications
  1.  ;; due to the neoplasm (including metastases) or its treatment, other than
  1.  ;; those already documented in the report above?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, list residual conditions and complications (brief summary):
  1.  ;;_____________________________________________________________________________
  1.  ;;
  1.  ;; e. If there are additional benign or malignant neoplasms or metastases
  1.  ;; related to any of the diagnoses in the Diagnosis section, describe using
  1.  ;; the above format: ___________________________________________________________
  1.  ;;
  1.  ;; 8. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;;
  1.  ;; Does the Veteran have any other pertinent physical findings, complications,
  1.  ;; conditions, signs and/or symptoms related to any conditions listed in the
  1.  ;; Diagnosis section above?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, describe: __________________________________________________________
  1.  ;;^TOF^
  1.  ;; 9. Functional impact
  1.  ;;
  1.  ;; Do any of the Veteran's skin conditions impact his or her ability to work?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, describe impact of each of the Veteran's skin conditions, providing
  1.  ;; one or more examples: ______________________________________________________
  1.  ;;
  1.  ;; 10. Remarks, if any:  ______________________________________________________
  1.  ;;
  1.  ;; Physician signature: _____________________________________ Date: ___________
  1.  ;;
  1.  ;; Physician printed name: ____________________________________________________
  1.  ;;
  1.  ;; Medical license #: _________________________________________________________
  1.  ;;
  1.  ;; Physician address: _________________________________________________________
  1.  ;;
  1.  ;; Phone: _____________________________     FAX: ______________________________
  1.  ;;
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's
  1.  ;; application.
  1.  ;;
  1.  ;;^END^
  1.  ;;
  1.  Q