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Routine: DVBCQSK5

DVBCQSK5.m

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  1. DVBCQSK5 ;;ALB-CIOFO/ECF -  SKIN DISEASES QUESTIONNAIRE ; 7/15/2011
  1.  ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
  1.  ;
  1. TXT ;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs
  1.  ;; (VA) for disability benefits.  VA will consider the information you
  1.  ;; provide on this questionnaire as part of their evaluation in processing
  1.  ;; the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis:
  1.  ;;
  1.  ;; Does the Veteran now have or has he/she ever had a skin condition?
  1.  ;; ___ Yes    ___ No
  1.  ;;
  1.  ;; If yes, provide only diagnoses that pertain to skin conditions. 
  1.  ;; Indicate the category of skin condition, and then provide specific
  1.  ;; diagnosis in that category (check all that apply):
  1.  ;; ___ Dermatitis or eczema
  1.  ;;     Diagnosis: ______________________     ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Infectious skin conditions (including bacterial, fungal,
  1.  ;;     viral, treponemal and parasitic skin conditions)
  1.  ;;     Diagnosis: ______________________     ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Bullous disorders
  1.  ;;     Diagnosis: ______________________     ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Psoriasis                             ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Exfoliative dermatitis (erythroderma) ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Cutaneous manifestations of collagen-vascular diseases
  1.  ;;     Diagnosis: ______________________     ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Papulosquamous skin disorders
  1.  ;;     Diagnosis: ______________________     ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Vitiligo
  1.  ;;     Diagnosis: ______________________     ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Keratinization skin disorders
  1.  ;;     Diagnosis: ______________________     ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Urticaria
  1.  ;;     Diagnosis: ______________________     ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Primary cutaneous vasculitis          ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Erythema multiforme                   ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Acne                                  ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;;^TOF^
  1.  ;; ___ Chloracne                             ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Alopecia                              ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Hyperhidrosis                         ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Tumors and neoplasms of the skin, including malignant melanoma
  1.  ;;     Diagnosis: ______________________     ICD code:  __________
  1.  ;;     Date of diagnosis: ______________
  1.  ;; ___ Other skin condition
  1.  ;;     Other diagnosis #1: ________________________________________________
  1.  ;;     ICD code:  _________________       Date of diagnosis: ______________
  1.  ;;     Other diagnosis #2: ________________________________________________
  1.  ;;     ICD code:  _________________       Date of diagnosis: ______________
  1.  ;;     Other diagnosis #3: ________________________________________________
  1.  ;;     ICD code:  _________________       Date of diagnosis: ______________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to the skin conditions, list
  1.  ;; using above format:
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 2. Medical History
  1.  ;;
  1.  ;; a. Describe the history (including onset and course) of the Veteran's skin
  1.  ;; conditions (brief summary): ________________________________________________
  1.  ;;
  1.  ;; b. Do any of the Veteran's skin conditions cause scarring or disfigurement
  1.  ;; of the head, face or neck?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, indicate skin condition and describe scarring and/or disfigurement:
  1.  ;; ____________________________________________________________________________
  1.  ;; Also complete the Scars Questionnaire if appropriate.
  1.  ;;
  1.  ;; c. Does the Veteran have any benign or malignant skin neoplasms (including
  1.  ;; malignant melanoma)?
  1.  ;; ___ Yes    ___ No
  1.  ;;
  1.  ;; d. Does the Veteran have any systemic manifestations due to any skin
  1.  ;; diseases (such as fever, weight loss or hypoproteinemia associated with skin
  1.  ;; conditions such as erythroderma)?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, describe: __________________________________________________________
  1.  ;; Also complete additional Questionnaires if appropriate.
  1.  ;;^TOF^
  1.  ;; 3. Treatment
  1.  ;;
  1.  ;; a. Has the Veteran been treated with oral or topical medications in the past
  1.  ;; 12 months for any skin condition?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;
  1.  ;; ___ Systemic corticosteroids or other immunosuppressive medications
  1.  ;;    If checked, list medication(s): _________________________________________
  1.  ;;    Specify condition medication used for: __________________________________
  1.  ;;    Total duration of medication use in past 12 months:
  1.  ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
  1.  ;;    ___  Constant/near-constant
  1.  ;;
  1.  ;; ___ Antihistamines
  1.  ;;    If checked, list medication(s): _________________________________________
  1.  ;;    Specify condition medication used for: __________________________________ 
  1.  ;;    Total duration of medication use in past 12 months:
  1.  ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
  1.  ;;    ___  Constant/near-constant
  1.  ;;
  1.  ;;  ___  Immunosuppressive retinoids
  1.  ;;    If checked, list medication(s): _________________________________________
  1.  ;;     Specify condition medication used for: _________________________________
  1.  ;;    Total duration of medication use in past 12 months:
  1.  ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
  1.  ;;    ___  Constant/near-constant
  1.  ;;
  1.  ;; ___ Sympathomimetics
  1.  ;;    If checked, list medication(s): _________________________________________
  1.  ;;    Specify condition medication used for: __________________________________
  1.  ;;    Total duration of medication use in past 12 months:
  1.  ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
  1.  ;;    ___  Constant/near-constant
  1.  ;;
  1.  ;; ___ Other oral medications
  1.  ;;    If checked, list medication(s): _________________________________________
  1.  ;;    Specify condition medication used for: __________________________________
  1.  ;;    Total duration of medication use in past 12 months:
  1.  ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
  1.  ;;    ___  Constant/near-constant
  1.  ;;
  1.  ;; ___ Topical corticosteroids
  1.  ;;    If checked, list medication(s): _________________________________________
  1.  ;;    Specify condition medication used for: __________________________________
  1.  ;;    Total duration of medication use in past 12 months:
  1.  ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
  1.  ;;    ___  Constant/near-constant
  1.  ;;^TOF^
  1.  ;; ___ Other topical medications
  1.  ;;    If checked, list medication(s): _________________________________________
  1.  ;;    Specify condition medication used for: __________________________________
  1.  ;;    Total duration of medication use in past 12 months:
  1.  ;;    ___  < 6 weeks    ___  6 weeks or more, but not constant
  1.  ;;    ___  Constant/near-constant
  1.  ;;
  1.  ;; NOTE: If a medication is used for more than one condition, provide names of
  1.  ;; all conditions, name of medication used for each condition, and frequency
  1.  ;; of use for each condition: _________________________________________________
  1.  ;;
  1.  ;; b. Has the Veteran had any treatments or procedures other than systemic or
  1.  ;; topical medications in the past 12 months for exfoliative dermatitis or
  1.  ;; papulosquamous disorders?
  1.  ;; ___ Yes    ___ No
  1.  ;;
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ PUVA (photo-chemotherapy with psoralen and ultraviolet A) treatment
  1.  ;;        If checked, specify condition treated: ______________________________
  1.  ;;        Date of most recent treatment: _______________
  1.  ;;        Total duration of treatment in past 12 months: 
  1.  ;;           ___  < 6 weeks    ___  6 weeks or more, but not constant
  1.  ;;           ___  Constant/near-constant
  1.  ;;
  1.  ;;    ___ UVB (ultraviolet B phototherapy) treatment
  1.  ;;        If checked, specify condition treated: ______________________________
  1.  ;;        Date of most recent treatment: _______________
  1.  ;;        Total duration of treatment in past 12 months:
  1.  ;;        ___  < 6 weeks    ___  6 weeks or more, but not constant
  1.  ;;        ___  Constant/near-constant
  1.  ;;
  1.  ;;    ___ Electron beam therapy
  1.  ;;        If checked, specify condition treated: ______________________________
  1.  ;;        Date of most recent treatment: _______________
  1.  ;;        Total duration of treatment in past 12 months:
  1.  ;;        ___  < 6 weeks    ___  6 weeks or more, but not constant
  1.  ;;        ___  Constant/near-constant
  1.  ;;
  1.  ;;    ___ Intensive light therapy
  1.  ;;        If checked, specify condition treated: ______________________________
  1.  ;;        Date of most recent treatment: _______________
  1.  ;;        Total duration of treatment in past 12 months:
  1.  ;;        ___  < 6 weeks    ___  6 weeks or more, but not constant
  1.  ;;        ___  Constant/near-constant
  1.  ;;^TOF^
  1.  ;;    ___ Other treatment
  1.  ;;        Specify treatment: __________________________________________________
  1.  ;;        Specify condition treated: __________________________________________
  1.  ;;        Date of most recent treatment: _______________
  1.  ;;        Total duration of treatment in past 12 months: 
  1.  ;;        ___  < 6 weeks    ___  6 weeks or more, but not constant
  1.  ;;        ___  Constant/near-constant
  1.  ;;
  1.  ;; 4. Debilitating and non-debilitating episodes
  1.  ;;
  1.  ;; a. Has the Veteran had any debilitating episodes in the past 12 months due
  1.  ;; to urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic
  1.  ;; epidermal necrolysis?
  1.  ;; ___ Yes    ___ No
  1.  ;;
  1.  ;; If yes, specify condition causing debilitating episodes:
  1.  ;; ___ urticaria             ___ primary cutaneous vasculitis
  1.  ;; ___ erythema multiforme   ___ toxic epidermal necrolysis
  1.  ;;    Describe debilitating episodes (brief summary): _________________________
  1.  ;;    Number of debilitating episodes in past 12 months:
  1.  ;;       ___  1    ___  2    ___  3   ___  4 or more
  1.  ;;    Characteristics of debilitating episodes
  1.  ;;      ___  Occurred despite ongoing immunosuppressive therapy
  1.  ;;      ___  Required treatment with intermittent systemic immunosuppressive
  1.  ;;           therapy
  1.  ;;      ___  Responded to treatment with antihistamines or sympathomimetics
  1.  ;;
  1.  ;; b. Has the Veteran had any non-debilitating episodes of urticaria, primary
  1.  ;; cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis in
  1.  ;; the past 12 months?
  1.  ;; ___ Yes    ___ No
  1.  ;;
  1.  ;; If yes, specify condition causing non-debilitating episodes:
  1.  ;; ___ urticaria             ___ primary cutaneous vasculitis
  1.  ;; ___ erythema multiforme   ___ toxic epidermal necrolysis
  1.  ;; Describe episodes (brief summary): ____________________
  1.  ;;    Number of non-debilitating episodes in past 12 months:
  1.  ;;       ___  1    ___  2    ___  3   ___  4 or more
  1.  ;;    Characteristics of non-debilitating episodes
  1.  ;;       ___  Occurred despite ongoing immunosuppressive therapy
  1.  ;;       ___  Required treatment with intermittent systemic immunosuppressive
  1.  ;;            therapy
  1.  ;;       ___  Responded to treatment with antihistamines or sympathomimetics
  1.  ;;       
  1.  ;; NOTE: If the Veteran's debilitating and/or non-debilitating episodes are due
  1.  ;; to more than one condition, provide names of all conditions, indicating
  1.  ;; severity and frequency of episodes for each condition: _____________________
  1.  ;;^TOF^
  1.  ;; 5. Physical exam
  1.  ;;
  1.  ;; a. Indicate the Veteran's visible skin conditions; indicate the approximate
  1.  ;; total body area and approximate total EXPOSED body area (face, neck and
  1.  ;; hands) affected on current examination (check all that apply):
  1.  ;;
  1.  ;; ___ Dermatitis
  1.  ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;
  1.  ;; ___ Eczema
  1.  ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;
  1.  ;; __ Bullous disorder
  1.  ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;
  1.  ;; __ Psoriasis
  1.  ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;
  1.  ;; ___ Infections of the skin
  1.  ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;
  1.  ;; ___ Cutaneous manifestations of collagen-vascular disease
  1.  ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;
  1.  ;; ___ Papulosquamous disorder
  1.  ;;  Total body area  ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;  EXPOSED area     ___None   ___<5%   ___5% to <20%   ___20% to 40%   ___>40%
  1.  ;;
  1.  ;; ___ The Veteran does not have any of the above listed visible skin
  1.  ;;     conditions
  1.  ;;
  1.  ;; b. For each skin condition, give specific diagnosis and describe appearance
  1.  ;; and location: ______________________________________________________________
  1.  Q