DVBCQSK6 ;;ALB-CIOFO/ECF - SKIN DISEASES QUESTIONNAIRE ; 7/15/2011
;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
;
TXT ;
;;^TOF^
;; 6. Specific Skin Conditions
;;
;; Indicate the Veteran's specific skin conditions and complete all applicable
;; subsequent questions (check all that apply):
;;
;; ___ Acne or Chloracne
;; If checked, indicate severity and location (check all that apply):
;; ___ Superficial acne (comedones, papules, pustules, superficial cysts)
;; of any extent
;; ___ Deep acne (deep inflamed nodules and pus-filled cysts)
;; ___ Affects less than 40% of face and neck
;; ___ Affects 40% or more of face and neck
;; ___ Affects body areas other than face and neck
;;
;; ___ Vitiligo
;; If checked, indicate areas affected by vitiligo:
;; ___ Exposed areas affected
;; ___ No exposed areas affected
;;
;; ___ Scarring alopecia
;; If checked, indicate percent of scalp affected:
;; ___ <20% ___ 20 to 40% ___ >40%
;;
;; ___ Alopecia areata
;; If checked, indicate amount of hair loss:
;; ___ Hair loss limited to scalp and face ___ Loss of all body hair
;; ___ Other, describe: ___________________________________________________
;;
;; ___ Hyperhidrosis
;; If checked, indicate severity:
;; ___ Able to handle paper or tools after treatment
;; ___ Unresponsive to treatment; unable to handle paper or tools
;;
;; ___ Veteran does not have any of the specific skin conditions listed above
;;
;; 7. Tumors and neoplasms
;;
;; a. Does the Veteran have a benign or malignant neoplasm or metastases
;; related to any of the diagnoses in the Diagnosis section?
;; ___ Yes ___ No
;; If yes, complete the following:
;;
;; b. Is the neoplasm
;; ___ Benign ___ Malignant
;;^TOF^
;; c. Has the Veteran completed treatment or is the Veteran currently
;; undergoing treatment for a benign or malignant neoplasm or metastases?
;; ___ Yes ___ No; watchful waiting
;; If yes, indicate type of treatment the Veteran is currently undergoing or
;; has completed (check all that apply):
;; ___ Treatment completed; currently in watchful waiting status
;; ___ Surgery
;; If checked, describe: __________________________________________________
;; Date(s) of surgery: _____________________
;; ___ Radiation therapy
;; Date of most recent treatment: ___________
;; Date of completion of treatment or anticipated date of completion: _____
;; ___ Antineoplastic chemotherapy
;; Date of most recent treatment: ___________
;; Date of completion of treatment or anticipated date of completion: _____
;; ___ Other therapeutic procedure
;; If checked, describe procedure: ________________________________________
;; Date of most recent procedure: __________
;; ___ Other therapeutic treatment
;; If checked, describe treatment: ________________________________________
;; Date of completion of treatment or anticipated date of completion:______
;;
;; d. Does the Veteran currently have any residual conditions or complications
;; due to the neoplasm (including metastases) or its treatment, other than
;; those already documented in the report above?
;; ___ Yes ___ No
;; If yes, list residual conditions and complications (brief summary):
;; ____________________________________________________________________________
;;
;; e. If there are additional benign or malignant neoplasms or metastases
;; related to any of the diagnoses in the Diagnosis section, describe using
;; the above format: ___________________________________________________________
;;
;; 8. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;;
;; 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: __________________________________________________________
;;^TOF^
;; 9. Functional impact
;;
;; Do any of the Veteran's skin conditions impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe impact of each of the Veteran's skin conditions, providing
;; one or more examples: ______________________________________________________
;;
;; 10. 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
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQSK6 5131 printed Nov 22, 2024@16:58:26 Page 2
DVBCQSK6 ;;ALB-CIOFO/ECF - SKIN DISEASES QUESTIONNAIRE ; 7/15/2011
+1 ;;2.7;AMIE;**169**;Apr 10, 1995;Build 5
+2 ;
TXT ;
+1 ;;^TOF^
+2 ;; 6. Specific Skin Conditions
+3 ;;
+4 ;; Indicate the Veteran's specific skin conditions and complete all applicable
+5 ;; subsequent questions (check all that apply):
+6 ;;
+7 ;; ___ Acne or Chloracne
+8 ;; If checked, indicate severity and location (check all that apply):
+9 ;; ___ Superficial acne (comedones, papules, pustules, superficial cysts)
+10 ;; of any extent
+11 ;; ___ Deep acne (deep inflamed nodules and pus-filled cysts)
+12 ;; ___ Affects less than 40% of face and neck
+13 ;; ___ Affects 40% or more of face and neck
+14 ;; ___ Affects body areas other than face and neck
+15 ;;
+16 ;; ___ Vitiligo
+17 ;; If checked, indicate areas affected by vitiligo:
+18 ;; ___ Exposed areas affected
+19 ;; ___ No exposed areas affected
+20 ;;
+21 ;; ___ Scarring alopecia
+22 ;; If checked, indicate percent of scalp affected:
+23 ;; ___ <20% ___ 20 to 40% ___ >40%
+24 ;;
+25 ;; ___ Alopecia areata
+26 ;; If checked, indicate amount of hair loss:
+27 ;; ___ Hair loss limited to scalp and face ___ Loss of all body hair
+28 ;; ___ Other, describe: ___________________________________________________
+29 ;;
+30 ;; ___ Hyperhidrosis
+31 ;; If checked, indicate severity:
+32 ;; ___ Able to handle paper or tools after treatment
+33 ;; ___ Unresponsive to treatment; unable to handle paper or tools
+34 ;;
+35 ;; ___ Veteran does not have any of the specific skin conditions listed above
+36 ;;
+37 ;; 7. Tumors and neoplasms
+38 ;;
+39 ;; a. Does the Veteran have a benign or malignant neoplasm or metastases
+40 ;; related to any of the diagnoses in the Diagnosis section?
+41 ;; ___ Yes ___ No
+42 ;; If yes, complete the following:
+43 ;;
+44 ;; b. Is the neoplasm
+45 ;; ___ Benign ___ Malignant
+46 ;;^TOF^
+47 ;; c. Has the Veteran completed treatment or is the Veteran currently
+48 ;; undergoing treatment for a benign or malignant neoplasm or metastases?
+49 ;; ___ Yes ___ No; watchful waiting
+50 ;; If yes, indicate type of treatment the Veteran is currently undergoing or
+51 ;; has completed (check all that apply):
+52 ;; ___ Treatment completed; currently in watchful waiting status
+53 ;; ___ Surgery
+54 ;; If checked, describe: __________________________________________________
+55 ;; Date(s) of surgery: _____________________
+56 ;; ___ Radiation therapy
+57 ;; Date of most recent treatment: ___________
+58 ;; Date of completion of treatment or anticipated date of completion: _____
+59 ;; ___ Antineoplastic chemotherapy
+60 ;; Date of most recent treatment: ___________
+61 ;; Date of completion of treatment or anticipated date of completion: _____
+62 ;; ___ Other therapeutic procedure
+63 ;; If checked, describe procedure: ________________________________________
+64 ;; Date of most recent procedure: __________
+65 ;; ___ Other therapeutic treatment
+66 ;; If checked, describe treatment: ________________________________________
+67 ;; Date of completion of treatment or anticipated date of completion:______
+68 ;;
+69 ;; d. Does the Veteran currently have any residual conditions or complications
+70 ;; due to the neoplasm (including metastases) or its treatment, other than
+71 ;; those already documented in the report above?
+72 ;; ___ Yes ___ No
+73 ;; If yes, list residual conditions and complications (brief summary):
+74 ;; ____________________________________________________________________________
+75 ;;
+76 ;; e. If there are additional benign or malignant neoplasms or metastases
+77 ;; related to any of the diagnoses in the Diagnosis section, describe using
+78 ;; the above format: ___________________________________________________________
+79 ;;
+80 ;; 8. Other pertinent physical findings, complications, conditions, signs
+81 ;; and/or symptoms
+82 ;;
+83 ;; Does the Veteran have any other pertinent physical findings, complications,
+84 ;; conditions, signs and/or symptoms related to any conditions listed in the
+85 ;; Diagnosis section above?
+86 ;; ___ Yes ___ No
+87 ;; If yes, describe: __________________________________________________________
+88 ;;^TOF^
+89 ;; 9. Functional impact
+90 ;;
+91 ;; Do any of the Veteran's skin conditions impact his or her ability to work?
+92 ;; ___ Yes ___ No
+93 ;; If yes, describe impact of each of the Veteran's skin conditions, providing
+94 ;; one or more examples: ______________________________________________________
+95 ;;
+96 ;; 10. Remarks, if any: ______________________________________________________
+97 ;;
+98 ;; Physician signature: _____________________________________ Date: ___________
+99 ;;
+100 ;; Physician printed name: ____________________________________________________
+101 ;;
+102 ;; Medical license #: _________________________________________________________
+103 ;;
+104 ;; Physician address: _________________________________________________________
+105 ;;
+106 ;; Phone: _____________________________ FAX: ______________________________
+107 ;;
+108 ;; NOTE: VA may request additional medical information, including additional
+109 ;; examinations if necessary to complete VA's review of the Veteran's
+110 ;; application.
+111 ;;
+112 ;;^END^
+113 ;;
+114 QUIT
