DVBCQSL2 ;;ALB-CIOFO/ECF - SLEEP APNEA QUESTIONNAIRE ;6/10/2011
;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
;
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 have or has he/she ever had sleep apnea?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to sleep apnea and check
;; diagnostic type:
;; ___ Obstructive ICD code: _______________ Date of diagnosis: _____________
;; ___ Central ICD code: _______________ Date of diagnosis: _____________
;; ___ Mixed, components of both
;; ICD code: _______________ Date of diagnosis: _____________
;; ___ Other sleep disorder, specify: _________________________________________
;; ICD code: _______________ Date of diagnosis: _____________
;;
;; If there are additional diagnoses that pertain to a diagnosis of sleep apnea
;; list using above format: ___________________________________________________
;;
;; NOTE: The diagnosis of sleep apnea must be confirmed by a sleep study;
;; provide sleep study results in Diagnostic testing section.
;;
;; If other respiratory condition is diagnosed, complete the Respiratory and/or
;; Narcolepsy Questionnaire(s), in lieu of this one.
;;
;; 2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's sleep
;; disorder condition (brief summary): ________________________________________
;;
;; b. Is continuous medication required for control of a sleep disorder
;; condition?
;; ___ Yes ___ No
;; If yes, list only those medications required for the Veteran's sleep
;; disorder condition: ________________________________________________________
;;
;; c. Does the Veteran require the use of a breathing assistance device such
;; as continuous positive airway pressure (CPAP) machine?
;; ___ Yes ___ No
;;^TOF^
;; 3. Findings, signs and symptoms
;;
;; Does the Veteran currently have any findings, signs or symptoms attributable
;; to sleep apnea?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Persistent daytime hypersomnolence
;; ___ Evidence of chronic respiratory failure with carbon dioxide retention
;; ___ Cor pulmonale
;; ___ Requires tracheostomy
;; ___ Other, describe: ____________________________________________________
;;
;; 4. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;;
;; a. Does the Veteran have any scars (surgical or otherwise) related to any
;; conditions or to the treatment of any conditions listed in the Diagnosis
;; section above?
;; ___ Yes ___ No
;;
;; If yes, are any of the scars painful and/or unstable, or is the total area
;; of all related scars greater than 39 square cm (6 square inches)?
;; ___ Yes ___ No
;; If yes, also complete a Scars Questionnaire.
;;
;; b. 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 (brief summary): __________________________________________
;;
;; 5. Diagnostic testing
;;
;; NOTE: If diagnostic test results are in the medical record and reflect the
;; Veteran's current sleep apnea condition, repeat testing is not required.
;;
;; a. Has a sleep study been performed?
;; ___ Yes ___ No
;; If yes, does the Veteran have documented sleep disorder breathing?
;; ___ Yes ___ No
;; Date of sleep study: ________________
;; Facility where sleep study performed, if known: _________________________
;; Results: ________________________________________________________________
;;
;; b. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;^TOF^
;; 6. Functional impact
;;
;; Does the Veteran's sleep apnea impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe impact of the Veteran's sleep apnea, providing one or more
;; examples: __________________________________________________________________
;;
;; 7. Remarks, if any: ________________________________________________________
;; ____________________________________________________________________________
;;
;; Physician signature: ____________________________________ Date: ____________
;;
;; Physician printed name: _________________________________ Phone: ___________
;;
;; Medical license #: ______________________________________ FAX: _____________
;;
;; Physician address: _________________________________________________________
;;
;; 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[HDVBCQSL2 5293 printed Apr 09, 2024@20:47:06 Page 2
DVBCQSL2 ;;ALB-CIOFO/ECF - SLEEP APNEA QUESTIONNAIRE ;6/10/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran have or has he/she ever had sleep apnea?
+10 ;; ___ Yes ___ No
+11 ;;
+12 ;; If yes, provide only diagnoses that pertain to sleep apnea and check
+13 ;; diagnostic type:
+14 ;; ___ Obstructive ICD code: _______________ Date of diagnosis: _____________
+15 ;; ___ Central ICD code: _______________ Date of diagnosis: _____________
+16 ;; ___ Mixed, components of both
+17 ;; ICD code: _______________ Date of diagnosis: _____________
+18 ;; ___ Other sleep disorder, specify: _________________________________________
+19 ;; ICD code: _______________ Date of diagnosis: _____________
+20 ;;
+21 ;; If there are additional diagnoses that pertain to a diagnosis of sleep apnea
+22 ;; list using above format: ___________________________________________________
+23 ;;
+24 ;; NOTE: The diagnosis of sleep apnea must be confirmed by a sleep study;
+25 ;; provide sleep study results in Diagnostic testing section.
+26 ;;
+27 ;; If other respiratory condition is diagnosed, complete the Respiratory and/or
+28 ;; Narcolepsy Questionnaire(s), in lieu of this one.
+29 ;;
+30 ;; 2. Medical history
+31 ;;
+32 ;; a. Describe the history (including onset and course) of the Veteran's sleep
+33 ;; disorder condition (brief summary): ________________________________________
+34 ;;
+35 ;; b. Is continuous medication required for control of a sleep disorder
+36 ;; condition?
+37 ;; ___ Yes ___ No
+38 ;; If yes, list only those medications required for the Veteran's sleep
+39 ;; disorder condition: ________________________________________________________
+40 ;;
+41 ;; c. Does the Veteran require the use of a breathing assistance device such
+42 ;; as continuous positive airway pressure (CPAP) machine?
+43 ;; ___ Yes ___ No
+44 ;;^TOF^
+45 ;; 3. Findings, signs and symptoms
+46 ;;
+47 ;; Does the Veteran currently have any findings, signs or symptoms attributable
+48 ;; to sleep apnea?
+49 ;; ___ Yes ___ No
+50 ;; If yes, check all that apply:
+51 ;; ___ Persistent daytime hypersomnolence
+52 ;; ___ Evidence of chronic respiratory failure with carbon dioxide retention
+53 ;; ___ Cor pulmonale
+54 ;; ___ Requires tracheostomy
+55 ;; ___ Other, describe: ____________________________________________________
+56 ;;
+57 ;; 4. Other pertinent physical findings, complications, conditions, signs
+58 ;; and/or symptoms
+59 ;;
+60 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+61 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+62 ;; section above?
+63 ;; ___ Yes ___ No
+64 ;;
+65 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+66 ;; of all related scars greater than 39 square cm (6 square inches)?
+67 ;; ___ Yes ___ No
+68 ;; If yes, also complete a Scars Questionnaire.
+69 ;;
+70 ;; b. Does the Veteran have any other pertinent physical findings,
+71 ;; complications, conditions, signs and/or symptoms related to any conditions
+72 ;; listed in the Diagnosis section above?
+73 ;; ___ Yes ___ No
+74 ;; If yes, describe (brief summary): __________________________________________
+75 ;;
+76 ;; 5. Diagnostic testing
+77 ;;
+78 ;; NOTE: If diagnostic test results are in the medical record and reflect the
+79 ;; Veteran's current sleep apnea condition, repeat testing is not required.
+80 ;;
+81 ;; a. Has a sleep study been performed?
+82 ;; ___ Yes ___ No
+83 ;; If yes, does the Veteran have documented sleep disorder breathing?
+84 ;; ___ Yes ___ No
+85 ;; Date of sleep study: ________________
+86 ;; Facility where sleep study performed, if known: _________________________
+87 ;; Results: ________________________________________________________________
+88 ;;
+89 ;; b. Are there any other significant diagnostic test findings and/or results?
+90 ;; ___ Yes ___ No
+91 ;; If yes, provide type of test or procedure, date and results (brief summary):
+92 ;; ____________________________________________________________________________
+93 ;;^TOF^
+94 ;; 6. Functional impact
+95 ;;
+96 ;; Does the Veteran's sleep apnea impact his or her ability to work?
+97 ;; ___ Yes ___ No
+98 ;; If yes, describe impact of the Veteran's sleep apnea, providing one or more
+99 ;; examples: __________________________________________________________________
+100 ;;
+101 ;; 7. Remarks, if any: ________________________________________________________
+102 ;; ____________________________________________________________________________
+103 ;;
+104 ;; Physician signature: ____________________________________ Date: ____________
+105 ;;
+106 ;; Physician printed name: _________________________________ Phone: ___________
+107 ;;
+108 ;; Medical license #: ______________________________________ FAX: _____________
+109 ;;
+110 ;; Physician address: _________________________________________________________
+111 ;;
+112 ;; NOTE: VA may request additional medical information, including additional
+113 ;; examinations if necessary to complete VA's review of the Veteran's
+114 ;; application.
+115 ;;
+116 ;; ^END^
+117 QUIT
