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Routine: DVBCQTB2

DVBCQTB2.m

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  1. DVBCQTB2 ;;ALB-CIOFO/ECF,SBW -  TUBERCULOSIS QUESTIONNAIRE ; 4/APR/2011
  1.  ;;2.7;AMIE;**166**;Apr 10, 1995;Build 6
  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.  ;; a. Does the Veteran now have or has he/she ever been diagnosed with
  1.  ;; active or latent tuberculosis (TB)?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; b. If no, has the Veteran had a positive skin test for TB without active
  1.  ;; disease?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; c. If no, has the Veteran had a positive quantiferon-TB gold test without
  1.  ;; active disease?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes to either question a, b or c above, provide only diagnoses that
  1.  ;; pertain to TB conditions:
  1.  ;; Diagnosis #1: ____________________
  1.  ;; ICD code: ________________________
  1.  ;; Date of diagnosis: _______________
  1.  ;;
  1.  ;; Diagnosis #2: ____________________
  1.  ;; ICD code: ________________________
  1.  ;; Date of diagnosis: _______________
  1.  ;;
  1.  ;; Diagnosis #3: ____________________
  1.  ;; ICD code: ________________________
  1.  ;; Date of diagnosis: _______________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to TB, list using above
  1.  ;; format:______________________________________________________________________
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;;
  1.  ;; a. Describe the history (including onset and course) of the Veteran's TB
  1.  ;; condition (brief summary): __________________________________________________
  1.  ;;
  1.  ;; b. Is the Veteran undergoing treatment or has he or she completed treatment
  1.  ;; for a TB condition, including active TB, positive skin test or laboratory
  1.  ;; evidence of TB (positive quantiferon-TB gold test) without active disease?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, complete the following:
  1.  ;;    Date treatment began: ____________
  1.  ;;    If completed, date of completion: ___________
  1.  ;;    If not completed, anticipated date of completion: ____________
  1.  ;;
  1.  ;; c. List medications currently or previously used for treatment of TB
  1.  ;;    condition: ______________________________________________________
  1.  ;;
  1.  ;; 3. Pulmonary TB
  1.  ;;
  1.  ;; a. Does the Veteran now have or has he or she ever been diagnosed with 
  1.  ;; pulmonary tuberculosis?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, is the condition:
  1.  ;;    ___ Active
  1.  ;;    ___ Inactive
  1.  ;;    If inactive, date condition became inactive: ______________________
  1.  ;;
  1.  ;; b. Does the Veteran have any residual findings, signs and/or symptoms due to
  1.  ;; pulmonary TB?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, indicate residuals:
  1.  ;;    ___ Emphysema
  1.  ;;    ___ Dyspnea on exertion
  1.  ;;    ___ Requires oxygen therapy
  1.  ;;    ___ Episodes of acute respiratory failure
  1.  ;;    ___ Moderately advanced lesions
  1.  ;;    ___ Far advanced lesions (diagnosed at any time while the disease process
  1.  ;;        was active)
  1.  ;;    ___ Pulmonary hypertension
  1.  ;;    ___ Right ventricular hypertrophy
  1.  ;;    ___ Cor pulmonale (right heart failure)
  1.  ;;    ___ Impairment of health
  1.  ;;         If checked, describe: ________________________________________________
  1.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;
  1.  ;; c. Has the Veteran had thoracoplasty due to TB?
  1.  ;; ___ Yes   ___ No        Date of procedure: ____________
  1.  ;;
  1.  ;; If yes, has the Veteran had resection of any ribs incident to thoracoplasty?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, indicate number of ribs involved:
  1.  ;; ___ 1    ___ 2    ___ 3 or 4    ___ 5 or 6    ___ More than 6
  1.  ;;^TOF^
  1.  ;; 4. Non-pulmonary TB
  1.  ;;
  1.  ;; a. Does the Veteran now have or has he or she ever been diagnosed with
  1.  ;; non-pulmonary tuberculosis?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, check all non-pulmonary TB conditions that apply:
  1.  ;;
  1.  ;;    ___ Tuberculous pleurisy
  1.  ;;    ___ Tuberculous peritonitis
  1.  ;;    ___ Tuberculosis meningitis
  1.  ;;    ___ Skeletal TB
  1.  ;;    ___ Genitourinary TB
  1.  ;;    ___ Gastrointestinal TB
  1.  ;;    ___ Tuberculous lymphadenitis
  1.  ;;    ___ Cutaneous TB
  1.  ;;    ___ Ocular TB
  1.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;
  1.  ;; b. For all checked conditions, indicate whether the condition is active
  1.  ;; or inactive; if inactive, provide date condition became inactive:
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; c. Does the Veteran have any residuals from any of the above non-pulmonary TB
  1.  ;; conditions?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe: ___________________________________________________________
  1.  ;; ALSO complete appropriate Questionnaires for the specific residual conditions.
  1.  ;;
  1.  ;; 5. Other pertinent physical findings, complications, conditions, signs and/or
  1.  ;; symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, are any of the scars painful and/or unstable, or is the total area
  1.  ;; of all related scars greater than 39 square cm (6 square inches)?
  1.  ;;    ___ Yes   ___ No 
  1.  ;;        If yes, also complete a Scars Questionnaire.
  1.  ;;
  1.  ;; b. Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs or symptoms?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe (brief summary): ___________________________________________
  1.  ;;^TOF^
  1.  ;; 6. Diagnostic testing
  1.  ;;
  1.  ;; NOTE: If test results are in the medical record and reflect the Veteran's 
  1.  ;; current respiratory condition, repeat testing is not required.
  1.  ;;
  1.  ;; a. Have imaging studies or procedures been performed?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Chest x-ray                       Date: ________ Results: ____________
  1.  ;;    ___ Magnetic resonance imaging (MRI)  Date: ________ Results: ____________
  1.  ;;    ___ Computed tomography (CT)          Date: ________ Results: ____________
  1.  ;;    ___ High resolution computed tomography to evaluate interstitial lung
  1.  ;;        disease such as asbestosis (HRCT) Date: ________ Results: ____________
  1.  ;;    ___ Other: _____________              Date: ________ Results: ____________
  1.  ;;
  1.  ;; b. Has pulmonary function testing (PFT) been performed?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, do PFT results reported below reflect the Veteran's current pulmonary
  1.  ;; function?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; c. Pulmonary function testing is not required in all instances. If PFTs have
  1.  ;; not been completed, provide reason:
  1.  ;;    ___ Veteran requires outpatient oxygen therapy
  1.  ;;    ___ Veteran has had 1 or more episodes of acute respiratory failure
  1.  ;;    ___ Veteran has been diagnosed with cor pulmonale, right ventricular
  1.  ;;        hypertrophy or pulmonary hypertension
  1.  ;;    ___ Veteran has had exercise capacity testing and results are 20 ml/kg/min
  1.  ;;        or less
  1.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;
  1.  ;; d. PFT results
  1.  ;;
  1.  ;;     Date: __________________
  1.  ;;
  1.  ;;     Pre-bronchodilator:                Post-bronchodilator, if indicated:
  1.  ;;         FEV-1:     ______% predicted       FEV-1:     ______% predicted
  1.  ;;         FVC:       ______% predicted       FVC:       ______% predicted
  1.  ;;         FEV-1/FVC: ______% predicted       FEV-1/FVC: ______% predicted
  1.  ;;         DLCO:      ______% predicted       DLCO:      ______% predicted
  1.  ;;
  1.  ;; e. Which test result most accurately reflects the Veteran's current
  1.  ;; pulmonary function?
  1.  ;;    ___ FEV-1
  1.  ;;    ___ FEV-1/FVC
  1.  ;;    ___ FVC
  1.  ;;    ___ DLCO
  1.  ;;^TOF^
  1.  ;; f. If post-bronchodilator testing has not been completed, provide reason:
  1.  ;;    ___ Pre-bronchodilator results are normal
  1.  ;;    ___ Post-bronchodilator testing not indicated for Veteran's condition
  1.  ;;    ___ Post-bronchodilator testing not indicated in Veteran's particular case
  1.  ;;         If checked, provide reason: ___________________
  1.  ;;    ___ Other, describe: ________________
  1.  ;;
  1.  ;; g. If Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath
  1.  ;; Method (DLCO) testing has not been completed, provide reason:
  1.  ;;    ___ Not indicated for Veteran's condition
  1.  ;;    ___ Not indicated in Veteran's particular case
  1.  ;;    ___ Not valid for Veteran's particular case
  1.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;
  1.  ;; h. Does the Veteran have multiple respiratory conditions?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, list conditions and indicate which condition is predominantly
  1.  ;; responsible for the limitation in pulmonary function, if any limitation
  1.  ;; is present: _________________________________________________________________
  1.  ;;
  1.  ;; i. Has exercise capacity testing been performed? 
  1.  ;; ___ Yes   ___ No  
  1.  ;; If yes, complete the following:
  1.  ;; ___ Maximum exercise capacity less than 15 ml/kg/min oxygen consumption 
  1.  ;;     (with cardiac or respiratory limitation)
  1.  ;; ___ Maximum oxygen consumption of 15 - 20 ml/kg/min (with cardiorespiratory 
  1.  ;;     limit)
  1.  ;;
  1.  ;; j. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 7. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's tuberculosis condition impact his or her ability to
  1.  ;; work?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe impact of each of the Veteran's tuberculosis conditions,
  1.  ;; providing one or more examples: _____________________________________________
  1.  ;;^TOF^
  1.  ;; 8. Remarks, if any: _________________________________________________________
  1.  ;;
  1.  ;; _____________________________________________________________________________
  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.  Q