DVBCQTB2 ;;ALB-CIOFO/ECF,SBW - TUBERCULOSIS QUESTIONNAIRE ; 4/APR/2011
;;2.7;AMIE;**166**;Apr 10, 1995;Build 6
;
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
;;
;; a. Does the Veteran now have or has he/she ever been diagnosed with
;; active or latent tuberculosis (TB)?
;; ___ Yes ___ No
;;
;; b. If no, has the Veteran had a positive skin test for TB without active
;; disease?
;; ___ Yes ___ No
;;
;; c. If no, has the Veteran had a positive quantiferon-TB gold test without
;; active disease?
;; ___ Yes ___ No
;;
;; If yes to either question a, b or c above, provide only diagnoses that
;; pertain to TB conditions:
;; Diagnosis #1: ____________________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; Diagnosis #2: ____________________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; Diagnosis #3: ____________________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; If there are additional diagnoses that pertain to TB, list using above
;; format:______________________________________________________________________
;;
;; 2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's TB
;; condition (brief summary): __________________________________________________
;;
;; b. Is the Veteran undergoing treatment or has he or she completed treatment
;; for a TB condition, including active TB, positive skin test or laboratory
;; evidence of TB (positive quantiferon-TB gold test) without active disease?
;; ___ Yes ___ No
;;
;; If yes, complete the following:
;; Date treatment began: ____________
;; If completed, date of completion: ___________
;; If not completed, anticipated date of completion: ____________
;;
;; c. List medications currently or previously used for treatment of TB
;; condition: ______________________________________________________
;;
;; 3. Pulmonary TB
;;
;; a. Does the Veteran now have or has he or she ever been diagnosed with
;; pulmonary tuberculosis?
;; ___ Yes ___ No
;;
;; If yes, is the condition:
;; ___ Active
;; ___ Inactive
;; If inactive, date condition became inactive: ______________________
;;
;; b. Does the Veteran have any residual findings, signs and/or symptoms due to
;; pulmonary TB?
;; ___ Yes ___ No
;;
;; If yes, indicate residuals:
;; ___ Emphysema
;; ___ Dyspnea on exertion
;; ___ Requires oxygen therapy
;; ___ Episodes of acute respiratory failure
;; ___ Moderately advanced lesions
;; ___ Far advanced lesions (diagnosed at any time while the disease process
;; was active)
;; ___ Pulmonary hypertension
;; ___ Right ventricular hypertrophy
;; ___ Cor pulmonale (right heart failure)
;; ___ Impairment of health
;; If checked, describe: ________________________________________________
;; ___ Other, describe: _____________________________________________________
;;
;; c. Has the Veteran had thoracoplasty due to TB?
;; ___ Yes ___ No Date of procedure: ____________
;;
;; If yes, has the Veteran had resection of any ribs incident to thoracoplasty?
;; ___ Yes ___ No
;;
;; If yes, indicate number of ribs involved:
;; ___ 1 ___ 2 ___ 3 or 4 ___ 5 or 6 ___ More than 6
;;^TOF^
;; 4. Non-pulmonary TB
;;
;; a. Does the Veteran now have or has he or she ever been diagnosed with
;; non-pulmonary tuberculosis?
;; ___ Yes ___ No
;;
;; If yes, check all non-pulmonary TB conditions that apply:
;;
;; ___ Tuberculous pleurisy
;; ___ Tuberculous peritonitis
;; ___ Tuberculosis meningitis
;; ___ Skeletal TB
;; ___ Genitourinary TB
;; ___ Gastrointestinal TB
;; ___ Tuberculous lymphadenitis
;; ___ Cutaneous TB
;; ___ Ocular TB
;; ___ Other, describe: _____________________________________________________
;;
;; b. For all checked conditions, indicate whether the condition is active
;; or inactive; if inactive, provide date condition became inactive:
;; _____________________________________________________________________________
;;
;; c. Does the Veteran have any residuals from any of the above non-pulmonary TB
;; conditions?
;; ___ Yes ___ No
;;
;; If yes, describe: ___________________________________________________________
;; ALSO complete appropriate Questionnaires for the specific residual conditions.
;;
;; 5. 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 or symptoms?
;; ___ Yes ___ No
;;
;; If yes, describe (brief summary): ___________________________________________
;;^TOF^
;; 6. Diagnostic testing
;;
;; NOTE: If test results are in the medical record and reflect the Veteran's
;; current respiratory condition, repeat testing is not required.
;;
;; a. Have imaging studies or procedures been performed?
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ___ Chest x-ray Date: ________ Results: ____________
;; ___ Magnetic resonance imaging (MRI) Date: ________ Results: ____________
;; ___ Computed tomography (CT) Date: ________ Results: ____________
;; ___ High resolution computed tomography to evaluate interstitial lung
;; disease such as asbestosis (HRCT) Date: ________ Results: ____________
;; ___ Other: _____________ Date: ________ Results: ____________
;;
;; b. Has pulmonary function testing (PFT) been performed?
;; ___ Yes ___ No
;;
;; If yes, do PFT results reported below reflect the Veteran's current pulmonary
;; function?
;; ___ Yes ___ No
;;
;; c. Pulmonary function testing is not required in all instances. If PFTs have
;; not been completed, provide reason:
;; ___ Veteran requires outpatient oxygen therapy
;; ___ Veteran has had 1 or more episodes of acute respiratory failure
;; ___ Veteran has been diagnosed with cor pulmonale, right ventricular
;; hypertrophy or pulmonary hypertension
;; ___ Veteran has had exercise capacity testing and results are 20 ml/kg/min
;; or less
;; ___ Other, describe: _____________________________________________________
;;
;; d. PFT results
;;
;; Date: __________________
;;
;; Pre-bronchodilator: Post-bronchodilator, if indicated:
;; FEV-1: ______% predicted FEV-1: ______% predicted
;; FVC: ______% predicted FVC: ______% predicted
;; FEV-1/FVC: ______% predicted FEV-1/FVC: ______% predicted
;; DLCO: ______% predicted DLCO: ______% predicted
;;
;; e. Which test result most accurately reflects the Veteran's current
;; pulmonary function?
;; ___ FEV-1
;; ___ FEV-1/FVC
;; ___ FVC
;; ___ DLCO
;;^TOF^
;; f. If post-bronchodilator testing has not been completed, provide reason:
;; ___ Pre-bronchodilator results are normal
;; ___ Post-bronchodilator testing not indicated for Veteran's condition
;; ___ Post-bronchodilator testing not indicated in Veteran's particular case
;; If checked, provide reason: ___________________
;; ___ Other, describe: ________________
;;
;; g. If Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath
;; Method (DLCO) testing has not been completed, provide reason:
;; ___ Not indicated for Veteran's condition
;; ___ Not indicated in Veteran's particular case
;; ___ Not valid for Veteran's particular case
;; ___ Other, describe: _____________________________________________________
;;
;; h. Does the Veteran have multiple respiratory conditions?
;; ___ Yes ___ No
;;
;; If yes, list conditions and indicate which condition is predominantly
;; responsible for the limitation in pulmonary function, if any limitation
;; is present: _________________________________________________________________
;;
;; i. Has exercise capacity testing been performed?
;; ___ Yes ___ No
;; If yes, complete the following:
;; ___ Maximum exercise capacity less than 15 ml/kg/min oxygen consumption
;; (with cardiac or respiratory limitation)
;; ___ Maximum oxygen consumption of 15 - 20 ml/kg/min (with cardiorespiratory
;; limit)
;;
;; j. 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):
;; _____________________________________________________________________________
;;
;; 7. Functional impact
;;
;; Does the Veteran's tuberculosis condition impact his or her ability to
;; work?
;; ___ Yes ___ No
;;
;; If yes, describe impact of each of the Veteran's tuberculosis conditions,
;; providing one or more examples: _____________________________________________
;;^TOF^
;; 8. 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[HDVBCQTB2 10719 printed Apr 09, 2024@20:49:33 Page 2
DVBCQTB2 ;;ALB-CIOFO/ECF,SBW - TUBERCULOSIS QUESTIONNAIRE ; 4/APR/2011
+1 ;;2.7;AMIE;**166**;Apr 10, 1995;Build 6
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+2 ;; (VA) for disability benefits. VA will consider the information you
+3 ;; provide on this questionnaire as part of their evaluation in processing
+4 ;; the Veteran's claim.
+5 ;;
+6 ;; 1. Diagnosis
+7 ;;
+8 ;; a. Does the Veteran now have or has he/she ever been diagnosed with
+9 ;; active or latent tuberculosis (TB)?
+10 ;; ___ Yes ___ No
+11 ;;
+12 ;; b. If no, has the Veteran had a positive skin test for TB without active
+13 ;; disease?
+14 ;; ___ Yes ___ No
+15 ;;
+16 ;; c. If no, has the Veteran had a positive quantiferon-TB gold test without
+17 ;; active disease?
+18 ;; ___ Yes ___ No
+19 ;;
+20 ;; If yes to either question a, b or c above, provide only diagnoses that
+21 ;; pertain to TB conditions:
+22 ;; Diagnosis #1: ____________________
+23 ;; ICD code: ________________________
+24 ;; Date of diagnosis: _______________
+25 ;;
+26 ;; Diagnosis #2: ____________________
+27 ;; ICD code: ________________________
+28 ;; Date of diagnosis: _______________
+29 ;;
+30 ;; Diagnosis #3: ____________________
+31 ;; ICD code: ________________________
+32 ;; Date of diagnosis: _______________
+33 ;;
+34 ;; If there are additional diagnoses that pertain to TB, list using above
+35 ;; format:______________________________________________________________________
+36 ;;
+37 ;; 2. Medical history
+38 ;;
+39 ;; a. Describe the history (including onset and course) of the Veteran's TB
+40 ;; condition (brief summary): __________________________________________________
+41 ;;
+42 ;; b. Is the Veteran undergoing treatment or has he or she completed treatment
+43 ;; for a TB condition, including active TB, positive skin test or laboratory
+44 ;; evidence of TB (positive quantiferon-TB gold test) without active disease?
+45 ;; ___ Yes ___ No
+46 ;;
+47 ;; If yes, complete the following:
+48 ;; Date treatment began: ____________
+49 ;; If completed, date of completion: ___________
+50 ;; If not completed, anticipated date of completion: ____________
+51 ;;
+52 ;; c. List medications currently or previously used for treatment of TB
+53 ;; condition: ______________________________________________________
+54 ;;
+55 ;; 3. Pulmonary TB
+56 ;;
+57 ;; a. Does the Veteran now have or has he or she ever been diagnosed with
+58 ;; pulmonary tuberculosis?
+59 ;; ___ Yes ___ No
+60 ;;
+61 ;; If yes, is the condition:
+62 ;; ___ Active
+63 ;; ___ Inactive
+64 ;; If inactive, date condition became inactive: ______________________
+65 ;;
+66 ;; b. Does the Veteran have any residual findings, signs and/or symptoms due to
+67 ;; pulmonary TB?
+68 ;; ___ Yes ___ No
+69 ;;
+70 ;; If yes, indicate residuals:
+71 ;; ___ Emphysema
+72 ;; ___ Dyspnea on exertion
+73 ;; ___ Requires oxygen therapy
+74 ;; ___ Episodes of acute respiratory failure
+75 ;; ___ Moderately advanced lesions
+76 ;; ___ Far advanced lesions (diagnosed at any time while the disease process
+77 ;; was active)
+78 ;; ___ Pulmonary hypertension
+79 ;; ___ Right ventricular hypertrophy
+80 ;; ___ Cor pulmonale (right heart failure)
+81 ;; ___ Impairment of health
+82 ;; If checked, describe: ________________________________________________
+83 ;; ___ Other, describe: _____________________________________________________
+84 ;;
+85 ;; c. Has the Veteran had thoracoplasty due to TB?
+86 ;; ___ Yes ___ No Date of procedure: ____________
+87 ;;
+88 ;; If yes, has the Veteran had resection of any ribs incident to thoracoplasty?
+89 ;; ___ Yes ___ No
+90 ;;
+91 ;; If yes, indicate number of ribs involved:
+92 ;; ___ 1 ___ 2 ___ 3 or 4 ___ 5 or 6 ___ More than 6
+93 ;;^TOF^
+94 ;; 4. Non-pulmonary TB
+95 ;;
+96 ;; a. Does the Veteran now have or has he or she ever been diagnosed with
+97 ;; non-pulmonary tuberculosis?
+98 ;; ___ Yes ___ No
+99 ;;
+100 ;; If yes, check all non-pulmonary TB conditions that apply:
+101 ;;
+102 ;; ___ Tuberculous pleurisy
+103 ;; ___ Tuberculous peritonitis
+104 ;; ___ Tuberculosis meningitis
+105 ;; ___ Skeletal TB
+106 ;; ___ Genitourinary TB
+107 ;; ___ Gastrointestinal TB
+108 ;; ___ Tuberculous lymphadenitis
+109 ;; ___ Cutaneous TB
+110 ;; ___ Ocular TB
+111 ;; ___ Other, describe: _____________________________________________________
+112 ;;
+113 ;; b. For all checked conditions, indicate whether the condition is active
+114 ;; or inactive; if inactive, provide date condition became inactive:
+115 ;; _____________________________________________________________________________
+116 ;;
+117 ;; c. Does the Veteran have any residuals from any of the above non-pulmonary TB
+118 ;; conditions?
+119 ;; ___ Yes ___ No
+120 ;;
+121 ;; If yes, describe: ___________________________________________________________
+122 ;; ALSO complete appropriate Questionnaires for the specific residual conditions.
+123 ;;
+124 ;; 5. Other pertinent physical findings, complications, conditions, signs and/or
+125 ;; symptoms
+126 ;;
+127 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+128 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+129 ;; section above?
+130 ;; ___ Yes ___ No
+131 ;;
+132 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+133 ;; of all related scars greater than 39 square cm (6 square inches)?
+134 ;; ___ Yes ___ No
+135 ;; If yes, also complete a Scars Questionnaire.
+136 ;;
+137 ;; b. Does the Veteran have any other pertinent physical findings,
+138 ;; complications, conditions, signs or symptoms?
+139 ;; ___ Yes ___ No
+140 ;;
+141 ;; If yes, describe (brief summary): ___________________________________________
+142 ;;^TOF^
+143 ;; 6. Diagnostic testing
+144 ;;
+145 ;; NOTE: If test results are in the medical record and reflect the Veteran's
+146 ;; current respiratory condition, repeat testing is not required.
+147 ;;
+148 ;; a. Have imaging studies or procedures been performed?
+149 ;; ___ Yes ___ No
+150 ;;
+151 ;; If yes, check all that apply:
+152 ;; ___ Chest x-ray Date: ________ Results: ____________
+153 ;; ___ Magnetic resonance imaging (MRI) Date: ________ Results: ____________
+154 ;; ___ Computed tomography (CT) Date: ________ Results: ____________
+155 ;; ___ High resolution computed tomography to evaluate interstitial lung
+156 ;; disease such as asbestosis (HRCT) Date: ________ Results: ____________
+157 ;; ___ Other: _____________ Date: ________ Results: ____________
+158 ;;
+159 ;; b. Has pulmonary function testing (PFT) been performed?
+160 ;; ___ Yes ___ No
+161 ;;
+162 ;; If yes, do PFT results reported below reflect the Veteran's current pulmonary
+163 ;; function?
+164 ;; ___ Yes ___ No
+165 ;;
+166 ;; c. Pulmonary function testing is not required in all instances. If PFTs have
+167 ;; not been completed, provide reason:
+168 ;; ___ Veteran requires outpatient oxygen therapy
+169 ;; ___ Veteran has had 1 or more episodes of acute respiratory failure
+170 ;; ___ Veteran has been diagnosed with cor pulmonale, right ventricular
+171 ;; hypertrophy or pulmonary hypertension
+172 ;; ___ Veteran has had exercise capacity testing and results are 20 ml/kg/min
+173 ;; or less
+174 ;; ___ Other, describe: _____________________________________________________
+175 ;;
+176 ;; d. PFT results
+177 ;;
+178 ;; Date: __________________
+179 ;;
+180 ;; Pre-bronchodilator: Post-bronchodilator, if indicated:
+181 ;; FEV-1: ______% predicted FEV-1: ______% predicted
+182 ;; FVC: ______% predicted FVC: ______% predicted
+183 ;; FEV-1/FVC: ______% predicted FEV-1/FVC: ______% predicted
+184 ;; DLCO: ______% predicted DLCO: ______% predicted
+185 ;;
+186 ;; e. Which test result most accurately reflects the Veteran's current
+187 ;; pulmonary function?
+188 ;; ___ FEV-1
+189 ;; ___ FEV-1/FVC
+190 ;; ___ FVC
+191 ;; ___ DLCO
+192 ;;^TOF^
+193 ;; f. If post-bronchodilator testing has not been completed, provide reason:
+194 ;; ___ Pre-bronchodilator results are normal
+195 ;; ___ Post-bronchodilator testing not indicated for Veteran's condition
+196 ;; ___ Post-bronchodilator testing not indicated in Veteran's particular case
+197 ;; If checked, provide reason: ___________________
+198 ;; ___ Other, describe: ________________
+199 ;;
+200 ;; g. If Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath
+201 ;; Method (DLCO) testing has not been completed, provide reason:
+202 ;; ___ Not indicated for Veteran's condition
+203 ;; ___ Not indicated in Veteran's particular case
+204 ;; ___ Not valid for Veteran's particular case
+205 ;; ___ Other, describe: _____________________________________________________
+206 ;;
+207 ;; h. Does the Veteran have multiple respiratory conditions?
+208 ;; ___ Yes ___ No
+209 ;;
+210 ;; If yes, list conditions and indicate which condition is predominantly
+211 ;; responsible for the limitation in pulmonary function, if any limitation
+212 ;; is present: _________________________________________________________________
+213 ;;
+214 ;; i. Has exercise capacity testing been performed?
+215 ;; ___ Yes ___ No
+216 ;; If yes, complete the following:
+217 ;; ___ Maximum exercise capacity less than 15 ml/kg/min oxygen consumption
+218 ;; (with cardiac or respiratory limitation)
+219 ;; ___ Maximum oxygen consumption of 15 - 20 ml/kg/min (with cardiorespiratory
+220 ;; limit)
+221 ;;
+222 ;; j. Are there any other significant diagnostic test findings and/or results?
+223 ;; ___ Yes ___ No
+224 ;;
+225 ;; If yes, provide type of test or procedure, date and results (brief summary):
+226 ;; _____________________________________________________________________________
+227 ;;
+228 ;; 7. Functional impact
+229 ;;
+230 ;; Does the Veteran's tuberculosis condition impact his or her ability to
+231 ;; work?
+232 ;; ___ Yes ___ No
+233 ;;
+234 ;; If yes, describe impact of each of the Veteran's tuberculosis conditions,
+235 ;; providing one or more examples: _____________________________________________
+236 ;;^TOF^
+237 ;; 8. Remarks, if any: _________________________________________________________
+238 ;;
+239 ;; _____________________________________________________________________________
+240 ;;
+241 ;; Physician signature: _____________________________________ Date: ____________
+242 ;;
+243 ;; Physician printed name: _____________________________________________________
+244 ;;
+245 ;; Medical license #: __________________________________________________________
+246 ;;
+247 ;; Physician address: __________________________________________________________
+248 ;;
+249 ;; Phone: _____________________________ FAX: _______________________________
+250 ;;
+251 ;; NOTE: VA may request additional medical information, including additional
+252 ;; examinations if necessary to complete VA's review of the Veteran's
+253 ;; application.
+254 ;;
+255 ;;^END^
+256 QUIT
