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Routine: DVBCQSL2

DVBCQSL2.m

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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