Subjective/History Elements
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ESOPHAGUS

Describe the history (including onset and course) of the veteran’s esophageal conditions (e.g. GERD) (brief summary):
[frontload soapnote="subjective/drgfms-va-dbq-hpi"]

2b. Does the veteran’s treatment plan include taking continuous medication for the diagnosed condition? [select value="|no|yes"] (if “yes”, list only those medications used for the diagnosed condition):
[textarea cols=50 rows=5]

signs and symptoms

3. Does the veteran have any of the following signs or symptoms due to any esophageal conditions (including gerd)? [select value="|no|yes"] (if “yes,” check all that apply)

[checkbox value="symptoms productive of considerable impairment of health symptoms combination productive of severe impairment of health persistently recurrent epigastric distress| infrequent episodes of epigastric distress| dysphagia| pyrosis| reflux| regurgitation| pain substernal arm | sleep disturbance cause by esophageal reflux"]

if checked, indicate frequency of symptom recurrence per year:
[select value="|1|2|3|4 or more"]

if checked, indicate average duration of episodes of symptoms:
[select value="Less than 1 day| 1-9 days| 10 days or more"]

[checkbox value="material weight loss"]

if checked, provide baseline weight: [text] lbs.and current weight: [text] Lbs.
(for va purposes, baseline weight is the average weight for 2-year period preceding onset of disease)

[checkbox value="nausea"]
if checked, indicate frequency of episodes of nausea per year:
[select value="|1|2|3|4 or more"]
if checked, indicate average duration of episodes of nausea: Less than 1 day
[select value="Less than 1 day| 1-9 days| 10 days or more"]

[checkbox value="vomiting"]
if checked, indicate frequency of episodes of vomiting per year:
[select value="|1|2|3|4 or more"]
if checked, indicate average duration of episodes of vomiting:
[select value="|Less than 1 day|1-9 days|10 days or more"]

[checkbox value="hematemesis (vomiting blood)"]
if checked, indicate frequency of episodes of hematemesis per year:
[select value="|1|2|3|4 or more"]
if checked, indicate average duration of episodes of hematemesis:
[select value="|Less than 1 day|1-9 days|10 days or more"]

[checkbox value="melena with moderate anemia"]
if checked, provide hemoglobin/hematocrit in diagnostic testing section
if checked, indicate frequency of episodes of melena per year:
[select value="|1|2|3|4 or more"]
if checked, indicate average duration of episodes of melena:
[select value="|Less than 1 day|1-9 days|10 days or more"]

esophageal stricture, spasm and diverticulum
Does the veteran have an esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus?
[select value="|no|yes"] if yes, indicate severity of condition:
[select value="|Asymptomatic|not amenable to dilation|amenable to dilation|mild|moderate|severe"]
If checked, describe:
[textarea cols=50 rows=5]
[select value="|Permitting liquids only|permitting passage of liquids only, with marked impairment of general health"]

other pertinent physical findings, complications, conditions, signs, symptoms and scars

Does the veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to the conditions listed in the diagnosis section above? [select value="|no|yes"] if yes, describe (brief summary):
[textarea cols=50 rows=5]

5b. 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?
[select value="|no|yes"]
if yes, describe (brief summary):
[textarea cols=50 rows=5]

diagnostic testing

Have diagnostic imaging studies or other diagnostic procedures been performed? (if “yes,” check all that apply):
Upper endoscopy results: [text] date: [text]
Upper gi radiographic studies results: [text] date: [text]
Esophagram (barium swallow) results: [text] date: [text]
Mri results: [text] date: [text]
Ct results: [text] date: [text]
Biopsy specify body site: [text] results: [text] date: [text]
Other specify: [text] results: [text] date: [text]


Has laboratory testing been performed? (if “yes,” check all that apply):
[select value="|no|yes"]
cbc: [text] date: [text]
Platelets: [text] date: [text]
Helicobacter pylori results: [text] date: [text]
Hemoglobin: [text] date: [text]
Hematocrit: [text] date: [text]
White blood cell count: [text] date: [text]


Are there any other significant diagnostic test findings and/or results? (if “yes,” provide type of test or procedure, date and results in a brief summary):
[textarea cols=50 rows=5]

Section vii-functional impact
Do any of the veteran’s esophageal conditions impact his or her ability to work?
[frontload soapnote="subjective/va-dbq-work-impact"]
ESOPHAGUS

Describe the history (including onset and course) of the veteran’s esophageal conditions (e.g. GERD) (brief summary):


2b. Does the veteran’s treatment plan include taking continuous medication for the diagnosed condition? (if “yes”, list only those medications used for the diagnosed condition):


signs and symptoms

3. Does the veteran have any of the following signs or symptoms due to any esophageal conditions (including gerd)? (if “yes,” check all that apply)



if checked, indicate frequency of symptom recurrence per year:


if checked, indicate average duration of episodes of symptoms:




if checked, provide baseline weight: lbs.and current weight: Lbs.
(for va purposes, baseline weight is the average weight for 2-year period preceding onset of disease)


if checked, indicate frequency of episodes of nausea per year:

if checked, indicate average duration of episodes of nausea: Less than 1 day



if checked, indicate frequency of episodes of vomiting per year:

if checked, indicate average duration of episodes of vomiting:



if checked, indicate frequency of episodes of hematemesis per year:

if checked, indicate average duration of episodes of hematemesis:



if checked, provide hemoglobin/hematocrit in diagnostic testing section
if checked, indicate frequency of episodes of melena per year:

if checked, indicate average duration of episodes of melena:


esophageal stricture, spasm and diverticulum
Does the veteran have an esophageal stricture, spasm of esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus?
if yes, indicate severity of condition:

If checked, describe:



other pertinent physical findings, complications, conditions, signs, symptoms and scars

Does the veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to the conditions listed in the diagnosis section above? if yes, describe (brief summary):


5b. 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?

if yes, describe (brief summary):


diagnostic testing

Have diagnostic imaging studies or other diagnostic procedures been performed? (if “yes,” check all that apply):
Upper endoscopy results: date:
Upper gi radiographic studies results: date:
Esophagram (barium swallow) results: date:
Mri results: date:
Ct results: date:
Biopsy specify body site: results: date:
Other specify: results: date:


Has laboratory testing been performed? (if “yes,” check all that apply):

cbc: date:
Platelets: date:
Helicobacter pylori results: date:
Hemoglobin: date:
Hematocrit: date:
White blood cell count: date:


Are there any other significant diagnostic test findings and/or results? (if “yes,” provide type of test or procedure, date and results in a brief summary):


Section vii-functional impact
Do any of the veteran’s esophageal conditions impact his or her ability to work?
Functional Impact

Does the veteran's claimed condition impact his or her ability to work?

Result - Copy and paste this output:

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