Veteran Exam MA Workflow for [select name="examcontractor" value="LHI|QTC" memo=" <-- select exam contract company" memo_color="blue"] Scribed by: [text memo="<-- enter your name"]
=====================================================================================
Veteran's employment: [checkbox name="unemployed" value="" memo="unemployed/retired/disabled"][conditional field="unemployed" condition="(unemployed).is('')"]unemployed/retired/disabled, formerly employed as [comment memo_color="red" memo="IMPORTANT: if unemployed, you must specify the claimant's most recent paid occupation -->"][/conditional][text memo="<-- current or most recent paid occupation"][comment memo="For musculoskeletal exams "]Veteran's dominant hand: [select value="|right|left|ambidextrous"]
Does the veteran use any assistive devices? [select name="assistive" value="|no|yes"]
[conditional field="assistive" condition="(assistive).is('')||(assistive).is('yes')"][comment memo="If yes, identify assistive devices used (check all that apply and indicate frequency)"]
[checkbox value="wheelchair"] [select memo="<--frequency of use" value="|occasional|regular|constant"]
[checkbox value="brace"] [select memo="<--frequency of use" value="|occasional|regular|constant"]
[checkbox value="crutches"] [select memo="<--frequency of use" value="|occasional|regular|constant"]
[checkbox value="cane"] [select memo="<--frequency of use" value="|occasional|regular|constant"]
[checkbox value="walker"] [select memo="<--frequency of use" value="|occasional|regular|constant"]
[checkbox value="other"] [select memo="<--frequency of use" value="|occasional|regular|constant"][comment memo="If the veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: "]
[textarea cols=45 rows=2][/conditional]
=====================================================================================[comment memo="
select the DBQs requested for the veteran below and obtain indicated history" memo_color="blue"] [comment memo=" General Administrative" memo_color="yellow"] [checkbox name="SHA" memo="Separatiom Health Assessment DBQ (vitals and far and near vision needed)" value=""][conditional field="SHA" condition="(SHA).is('')"][frontload soapnote="subjective/drgfms-va-dbq-sha"]
=====================================================================================[/conditional][comment memo="Musculoskeletal" memo_color="yellow"] [checkbox name="Muscle" memo="Muscle DBQ" value=""][conditional field="Muscle" condition="(Muscle).is('')"][frontload soapnote="subjective/drgfms-va-dbq-muscle"]
=====================================================================================[/conditional] [checkbox name="TemporomandibularJointConditions" memo="Temporomandibular Joint Conditions DBQ" value=""][conditional field="TemporomandibularJointConditions" condition="(TemporomandibularJointConditions).is('')"][frontload soapnote="subjective/drgfms-va-dbq-tmj"]
=====================================================================================[/conditional] [checkbox name="Back" memo="Back DBQ" value=""][conditional field="Back" condition="(Back).is('')"][frontload soapnote="subjective/drgfms-va-dbq-back"]
=====================================================================================[/conditional] [checkbox name="Shoulder" memo="Shoulder DBQ" value=""][conditional field="Shoulder" condition="(Shoulder).is('')"][frontload soapnote="subjective/drgfms-va-dbq-shoulder"]
=====================================================================================[/conditional] [checkbox name="Hand" memo="Hand DBQ" value=""][conditional field="Hand" condition="(Hand).is('')"][frontload soapnote="subjective/drgfms-va-dbq-hand"]
=====================================================================================[/conditional] [checkbox name="HipandThigh" memo="Hip and Thigh DBQ" value=""][conditional field="HipandThigh" condition="(HipandThigh).is('')"][frontload soapnote="subjective/drgfms-va-dbq-hip"]
=====================================================================================[/conditional] [checkbox name="Knee" memo="Knee DBQ" value=""][conditional field="Knee" condition="(Knee).is('')"][frontload soapnote="subjective/drgfms-va-dbq_knee"]
=====================================================================================[/conditional] [checkbox name="Foot" memo="Foot DBQ" value=""][conditional field="Foot" condition="(Foot).is('')"][frontload soapnote="subjective/drgfms-va-dbq-foot"]
=====================================================================================[/conditional] [checkbox name="Ankle" memo="Ankle DBQ" value=""][conditional field="Ankle" condition="(Ankle).is('')"][frontload soapnote="subjective/drgfms-va-dbq-ankle"]
=====================================================================================[/conditional][comment memo="Neurologic" memo_color="yellow"] [checkbox name="Headaches" memo="Headaches DBQ" value=""][conditional field="Headaches" condition="(Headaches).is('')"][frontload soapnote="subjective/drgfms-va-dbq-headaches"]
=====================================================================================[/conditional] [checkbox name="SleepApnea" memo="Sleep Apnea DBQ" value=""][conditional field="SleepApnea" condition="(SleepApnea).is('')"][frontload soapnote="subjective/drgfms-va-dbq-sleep-apnea"]
=====================================================================================[/conditional] [checkbox name="Ear" memo="Ear DBQ" value=""][conditional field="Ear" condition="(Ear).is('')"][frontload soapnote="subjective/drgfms-va-dbq-ear"]
=====================================================================================[/conditional] [checkbox name="Peripheralnervesconditions" memo="Peripheral Nerves Conditions DBQ" value=""][conditional field="Peripheralnervesconditions" condition="(Peripheralnervesconditions).is('')"][frontload soapnote="subjective/drgfms-va-dbq-peripheral-nerves-conditions"]
=====================================================================================[/conditional][comment memo="Dermatologic" memo_color="yellow"] [checkbox name="Skin" memo="Skin DBQ" value=""][conditional field="Skin" condition="(Skin).is('')"][frontload soapnote="subjective/drgfms-va-dbq-skin"]
=====================================================================================[/conditional] [checkbox name="Scars" memo="Scars DBQ (complete if requested, or if veteran has painful, unstable, or extensive scars)" value=""][conditional field="Scars" condition="(Scars).is('')"][frontload soapnote="subjective/drgfms-va-dbq-scars"]
=====================================================================================[/conditional][comment memo="Internal Medicine" memo_color="yellow"] [checkbox name="Esophagus" memo="Esophagus DBQ" value=""][conditional field="Esophagus" condition="(Esophagus).is('')"][frontload soapnote="subjective/drgfms-va-dbq-esophagus"]
=====================================================================================[/conditional] [checkbox name="OtherIntestinalProblems" memo="Other Intestinal Problems DBQ" value=""][conditional field="OtherIntestinalProblems" condition="(OtherIntestinalProblems).is('')"][frontload soapnote="subjective/drgfms-va-dbq-int-other"]
=====================================================================================[/conditional] [checkbox name="Hepatitis" memo="Hepatitis DBQ" value=""][conditional field="Hepatitis" condition="(Hepatitis).is('')"][frontload soapnote="subjective/drgfms-dbq-liver"]
=====================================================================================[/conditional] [checkbox name="Kidney" memo="Kidney DBQ" value=""][conditional field="Kidney" condition="(Kidney).is('')"][frontload soapnote="subjective/drgfms-dbq-kidney"]
=====================================================================================[/conditional]
=====================================================================================
Does the veteran have any scars (surgical or othemise) related to any conditions or to the treatment of any conditions listed in the diagnosis section above? [select name="yn-scars" value="|no|yes"]
[conditional field="yn-scars" condition="(yn-scars).is('yes')||(yn-scars).is('')"][comment memo="If yes, describe"]
[textarea cols=45 rows=2][/conditional]
[checkbox name="Scars" memo="Scars DBQ (complete if requested, or if veteran has painful, unstable, or extensive scars)" value=""][conditional field="Scars" condition="(Scars).is('')"][frontload soapnote="subjective/drgfms-va-dbq-scars"]
=====================================================================================[/conditional]

Veteran Exam MA Workflow for <-- select exam contract company Scribed by: <-- enter your name
=====================================================================================
Veteran's employment: unemployed/retired/disabled<-- current or most recent paid occupationFor musculoskeletal exams Veteran's dominant hand:
Does the veteran use any assistive devices?

=====================================================================================
select the DBQs requested for the veteran below and obtain indicated history General Administrative Separatiom Health Assessment DBQ (vitals and far and near vision needed)Separation Health Exam

1. Did the veteran bring in any evidence that is not in the VA records for us to evaluate?

History of having symptoms currently or in the past:
For each condition, briefly describe the history, including date of onset and course.
2a. Head, face, neck and scalp:

2b. Nose:

2c. Sinuses:

2d. Mouth and throat:

2e. Ears:

2f. Eyes:

2g. Heart:

2h. Lungs and chest:

2i. Breasts:

2j. Vascular (varicosities, hypertension, etc):

2k. Anus and rectum (hemorrhoids, fistulae, prostate):

2l. Abdomen and viscera (include hernia):

2m. Genitourinary:

2n. Upper extremities:

2o. Lower extremities:

2p. Feet:

2q. Spine:

2r. Miscellaneous musculoskeletal conditions:

2s. Identifying body marks, scars, tattoos:

(Please describe the location and appearance of any marks, scars or tatoos)

2t. Skin, lymphatic:

2u. Neurologic:

2v. Psychiatric:

---------------------------------------------------------------------------
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:
1. Have had nightmares about it or thought about it when you did not want to?
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
3. Were constantly on guard, watchful, or easily startled?
4. Felt numb or detached from others, activities, or your surroundings?

Over the past two weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?

Ask the following:
Are you feeling hopeless about the present or future?
Have you had thoughts about taking your life?
If yes, when did you have these thoughts?
Do you have a plan to take your life?
Have you ever had a suicide attempt?
---------------------------------------------------------------------------
2W. Gynecologic (excluding breasts):

2X. Endocrine (e.g. Diabetes, thyroid problems, pituitary disorder):

2Y. Infectious disease, immune disorder or nutritional deficiency: (chronic fatigue syndrome, hiv and related illnesses, infectious disease, nutritional deficiencies, persian gulf and afghanistan infectious diseases, systemic lupus erythematosus or other immune disorder, or tuberculosis)

2Z. Miscellaneous conditions(cold injury, former prisoner of war, undiagnosed illness and unexplained chronic multi-symptom illness, or other):

3A. DOMINANT HAND:

3B. VITAL SIGNS
Blood Pressure #1:
Blood Pressure #2:
Blood Pressure #3:
Pulse rate:
Respiratory rate:
Height:
Weight:
3C. VISUAL ACUITY:
NEAR: RIGHT EYE UNCORRECTED 20/ LEFT EYE UNCORRECTED 20/
FAR: RIGHT EYE UNCORRECTED 20/ LEFT EYE UNCORRECTED 20/
NEAR: RIGHT EYE CORRECTED 20/ LEFT EYE CORRECTED 20/
FAR: RIGHT EYE CORRECTED 20/ LEFT EYE CORRECTED 20/
=====================================================================================Musculoskeletal Muscle DBQHistory Of Muscle Injury
Muscle Injuries DBQ

Does the Veteran have a penetrating muscle injury (such as a gunshot or shell fragment wound)?

Does the Veteran have a non-penetrating muscle injury (such as a muscle strain, torn achilles tendon or torn quadriceps muscle)?

Describe the history (including onset and course) of the Veteran's muscle injury (brief summary):

Does the Veteran now have or has he/she ever had an injury to a muscle group of the shoulder girdle or arm?

Does the Veteran now have or has he/she ever had an injury to a muscle group of the forearm or hand?

Does the Veteran now have or has he/she ever had an injury to a muscle group of the foot or leg?

Does the Veteran now have or has he/she ever had an injury to a muscle group of the pelvic girdle or thigh?

Does the Veteran now have or has he/she ever had an injury to a muscle group in the torso and/or neck?

Additional Conditions

Does the Veteran have a history of rupture of the diaphragm with herniation?

Does the Veteran have a history of an extensive muscle hernia of any muscle, without other injury to the muscle?

Does the Veteran have a history of injury to the facial muscles?

Does the Veteran have a history of Rhabdomyolysis?

Does the Veteran have a history of Compartment Syndrome?

Does the Veteran have any scar(s) associated with a muscle injury?

If yes, describe:

Does the Veteran have any known fascia defects or evidence of fascia defects associated with any muscle injuries?

If yes, describe:

Does the Veteran's muscle injury(ies) affect muscle substance or function?

If yes, describe:

Does the Veteran have any of the following signs and/or symptoms attributable to any muscle injuries?

Check all that apply, and indicate side affected, muscle group and frequency/severity:
Loss of power Weakness Lowered threshold of fatigue Fatigue and/or pain Impairment of coordination Uncertainty of movement

Have imaging studies been performed in conjunction with this examination?

If yes, describe date, facility, results:

Is there x-ray evidence of retained metallic fragments (such as shell fragments or shrapnel) in any muscle group?

If yes, describe date, facility, results:

Were electrodiagnostic tests done?

If yes, describe date, facility, results:

Are there any other significant diagnostic test findings and/or results?

If yes, describe:

Functional Impact

Does the Veteran's muscle injury(ies) impact his or her ability to work, such as resulting in inability to keep up with work requirements due to muscle injury(ies)?
Functional Impact

Does the veteran's claimed condition impact his or her ability to work?
===================================================================================== Temporomandibular Joint Conditions DBQVA Temporomandibular Joint Conditions DBQ

Describe the history (including onset and course) of the Veteran's temporomandibular joint condition only (brief summary):

Dominant hand:
Does the Veteran report flare-ups of the cervical spine (neck)?

Does the Veteran report flare-ups of the temporomandibular joint?
If yes, document the Veteran’s description of the impact of flare-ups on function in his or her own words:

Does the Veteran report having any functional loss or functional impairment of the temporomandibular joint (regardless of repetitive use)?
If yes, document the Veteran’s description of functional loss or functional impairment in his or her own words:

Right temporomandibular joint:
Is the Veteran able to perform repetitive-use testing with at least three repetitions?

Left temporomandibular joint:
Is the Veteran able to perform repetitive-use testing with at least three repetitions?

Right TMJ:
Is the examination being conducted during a flare up?
Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare ups?

Left TMJ:
Is the examination being conducted during a flare up?
Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare ups?

Does the Veteran require a mechanically altered foods diet, which has been physician verified or documented, due to the temporomandibular disorder?

Does the Veteran have any scars (surgical or otherwise) related to the temporomandibular joint claimed condition or to the treatment of the temporomandibular joint claimed condition?

Have imaging studies of the temporomandibular joint been performed and are the results available?
if yes, describe including date, study type, facility, results:

Regardless of the Veteran's current employment status, do the condition(s) listed in the diagnosis section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)?
Functional Impact

Does the veteran's claimed condition impact his or her ability to work?
===================================================================================== Back DBQBack (thoracolumbar spine) conditions
-------------------------------------

Describe the history (including onset and course) of the veteran's thoracolumbar spine (back) condition (brief summary):

Does the veteran report flare-ups of the thoracolumbar spine (back)?

Document the veteran's description of flare-ups in his or her own words:

Does the veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive
use)?

Document the veteran's description of functional loss or functional impairment in his or her own words:

Indicate frequency, severity and duration of flare-ups:
Frequency--
Severity--
Duration--
Things that cause flair ups--
Things that improve flair ups--

Range of motion
Does it hurt to move the back:
which movements hurt it? bending forward bending back bending to the right bending to the left turning to the right turning to the left

Repeated use over time
Is the veteran being examined immediately after use over time:
Does pain, weakness, fatigability or incoordination significantly limit functional ability with use over time?

Flare ups
Is the examination being conducted during a flare-up:
Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare ups?

localized tenderness-- does it hurt if someone presses n your back?
muscle spasm-- do you have back spasms?
guarding-- does pain force you to keep your back bent a certain way?

Muscle strength-- do you have leg weakness from your back problems?

Does the veteran have muscle atrophy?-- do you have waisting of muscles in your leg?

Section viii - radiculopathy
does the veteran have radicular pain or any other signs or symptoms due to radiculopathy?
Indicate symptoms' location and severity
constant pain (may be excruciating at times)
--right lower extremity:
--left lower extremity:
intermittent pain (usually dull)
--right lower extremity:
--left lower extremity:
paresthesias and/or dysesthesias (pins and needles)
--right lower extremity:
--left lower extremity:
numbness
--right lower extremity:
--left lower extremity:

Does the veteran have any other signs or symptoms of radiculopathy?
if yes, describe:

Does the veteran have IVDS of the thoracolumbar spine?

If yes to question 1 ia above, has the veteran had any episodes of acute signs and symptoms due to ivds that required bed rest
prescribed by a physician and treatment by a physican in the past 12 months?

if yes select the total duration over the past 12 months:

Does the veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the diagnosis section above?

Does the veteran have any scars (surgical or othemise) related to any conditions or to the treatment of any conditions listed in the diagnosis section above?

Have imaging studies of the thoracolumbar spine been performed and are the results available?

Does the veteran's thoracolumbar spine (back) condition impact his or her ability to work?
Functional Impact

Does the veteran's claimed condition impact his or her ability to work?
===================================================================================== Shoulder DBQshoulder conditions disability benefits questionnaire

medical history
---------------
Describe the history (including onset and course) of the veteran's shoulder and/or thigh condition (brief summary):

Does the veteran report flare-ups of the shoulder and/or thigh?
if yes, document the veteran's description of flare-ups in his or her own words:

Right:
------
Description of flare up:

Frequency:

Severity:

Duration:

Things that cause flare ups:

Things that improve flare ups:

left:
------
Description of flare up:

Frequency:

Severity:

Duration:

Things that cause flare ups:

Things that improve flare ups:

Functional loss
----------------
Does the veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this dbq (regardless of repetitive use)?

If yes, document the veteran's description of functional loss or functional impairment in his or her own words:

Initial range of motion (rom) and functional limitation
_______________________________________________________

Initial rom measurements
------------------------
right shoulder:
do you have a loss of range-of-motion in the right shoulder?
do you have tenderness in the shoulder if someone presses on it?
is there pain with weight bearing?
is there popping or grinding?

left shoulder:
do you have a loss of range-of-motion in the left shoulder?
do you have tenderness in the shoulder if someone presses on it?
is there pain with weight bearing?
is there popping or grinding?

Observed repetitive use:
will you be able to move the shoulders repeatedly through rom manuvers?

Flare ups shoulder
--------------

right shoulder:
is the examination being conducted immediately after repetitive use over time?
is the examination being conducted during a flare up?

left shoulder:
is the examination being conducted immediately after repetitive use over time?
is the examination being conducted during a flare up?

Muscle strength:
----------------
Do you have loss of muscle strength in the right shoulder?
do you have loss of muscle strength in the left shoulder?

Do yopu have muscle wasting or loss in the shoulders?
if yes, describe:

Surgical procedures
--------------------
Indicate any surgical procedures that the veteran has had performed.
if yes, describe date, facility, procedure:

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 any conditions listed in the diagnosis section above?

if yes, describe:

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:

Assistive devices
_________________
Does the veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible?

if yes, identify assistive devices used (check all that apply and indicate frequency):
Wheelchair frequency of use:
brace frequency of use:
crutches frequency of use:
cane frequency of use:
walker frequency of use:
other: Frequency of use:
If the veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition:

Diagnostic testing
------------------
Have imaging studies of the shoulders been performed and are the results available?
if yes, describe including date, study type, facility, results:

Functional impact
-----------------
Regardless of the veteran's current employment status, do the condition(s) listed in the diagnosis section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)?
Functional Impact

Does the veteran's claimed condition impact his or her ability to work?
===================================================================================== Hand DBQHand and finger conditions disability benefits questionnaire

Describe the history (including onset and course) of the veteran's hand, finger or thumb condition (brief summary):

Does the veteran report flare-ups of the hand, finger or thumb joints? Yes no
if yes, document the veteran's description of the flare-ups in his or her own words:

Right:
Frequency:

severity:

duration:

things that cause flair ups:

things that improve flair ups:

left:
Frequency:

severity:

duration:

things that cause flair ups:

things that improve flair ups:

Does the veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this dbq including but not limited to repeated use over time?

if yes, document the veteran's description of functional loss or functional impairment in his or her own words:

initial range of motion (rom) and functional limitation

initial range of motion
right hand
loss of rom in hand?
left hand
loss of rom in hand?

observed repetitive use
is the veteran able to perform repetitive-use testing with at least three repetitions?

left hand
is the veteran able to perform repetitive-use testing with at least three repetitions?

repeated use over time
hand
right hand
is the veteran being examined immediately after repetitive use over time?

left hand
is the veteran being examined immediately after repetitive use over time?

flare ups
is the exam being conducted during a flare up?
Right hand
left hand

muscle strength – is there weakness in the hands?
Right hand
left hand
does the veteran have muscle atrophy? (muscle wasting in the hands)
right hand
left hand

remaining effective function of the extremities
due to the veteran's hand, finger or thumb conditions, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis?

Diagnostic testing

have imaging studies of the hands been performed and are the results available?
which hand? Date? Procedure? Facility?

functional impact

Functional Impact

Does the veteran's claimed condition impact his or her ability to work?
===================================================================================== Hip and Thigh DBQHip and thigh conditions disability benefits questionnaire

medical history
---------------
Describe the history (including onset and course) of the veteran's hip and/or thigh condition (brief summary):

Does the veteran report flare-ups of the hip and/or thigh?
if yes, document the veteran's description of flare-ups in his or her own words:

Right:
------
Frequency:

Severity:

Duration:

Things that cause flair ups:

Things that improve flair ups:

left:
------
Frequency:

Severity:

Duration:

Things that cause flair ups:

Things that improve flair ups:

Functional loss
----------------
Does the veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this dbq (regardless of repetitive use)?

If yes, document the veteran's description of functional loss or functional impairment in his or her own words:

Initial range of motion (rom) and functional limitation
_______________________________________________________

Initial rom measurements
------------------------
right hip:
do you have a loss of range-of-motion in the right hip?
do you have tenderness in the hip if someone presses on it?
is there pain with weight bearing?
is there popping or grinding?

left hip:
do you have a loss of range-of-motion in the left hip?
do you have tenderness in the hip if someone presses on it?
is there pain with weight bearing?
is there popping or grinding?

Observed repetitive use:
will you be able to move the hips repeatedly through rom manuvers?

Flare ups hip
--------------

right hip:
is the examination being conducted immediately after repetitive use over time?
is the examination being conducted during a flare up?

left hip:
is the examination being conducted immediately after repetitive use over time?
is the examination being conducted during a flare up?

Muscle strength:
----------------
Do you have loss of muscle strength in the right hip?
do you have loss of muscle strength in the left hip?

Do yopu have muscle wasting or loss in the hips?
if yes, describe:

Surgical procedures
--------------------
Indicate any surgical procedures that the veteran has had performed.
if yes, describe date, facility, procedure:

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 any conditions listed in the diagnosis section above?

if yes, describe:

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:

Assistive devices
_________________
Does the veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible?

if yes, identify assistive devices used (check all that apply and indicate frequency):
Wheelchair frequency of use:
brace frequency of use:
crutches frequency of use:
cane frequency of use:
walker frequency of use:
other: Frequency of use:
If the veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition:

Diagnostic testing
------------------
Have imaging studies of the hip been performed and are the results available?
if yes, describe including date, study type, facility, results:

Functional impact
-----------------
Regardless of the veteran's current employment status, do the condition(s) listed in the diagnosis section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)?
Functional Impact

Does the veteran's claimed condition impact his or her ability to work?
===================================================================================== Knee DBQKnee and lower leg conditions disability benefits questionnaire

medical history
---------------
Describe the history (including onset and course) of the veteran's knee and/or lower leg condition (brief summary):

Does the veteran report flare-ups of the knee and/or lower leg?
if yes, document the veteran's description of flare-ups in his or her own words:

Right:
------
Frequency:

severity:

duration:

things that cause flair ups:

things that improve flair ups:

left:
------
Frequency:

severity:

duration:

things that cause flair ups:

things that improve flair ups:

functional loss
----------------
Does the veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this dbq (regardless of repetitive use)?

If yes, document the veteran's description of functional loss or functional impairment in his or her own words:

initial range of motion (rom) and functional limitation
_______________________________________________________

Initial rom measurements
------------------------
right knee:
do you have a loss of range-of-motion in the right knee?
do you have tenderness in the knee if someone presses on it?
is there pain with weight bearing?
is there popping or grinding?

left knee:
do you have a loss of range-of-motion in the left knee?
do you have tenderness in the knee if someone presses on it?
is there pain with weight bearing?
is there popping or grinding?

Observed repetitive use:
will you be able to move the knees repeatedly through rom manuvers?

Flare ups knee
--------------

right knee:
is the examination being conducted immediately after repetitive use over time?
is the examination being conducted during a flare up?

left knee:
is the examination being conducted immediately after repetitive use over time?
is the examination being conducted during a flare up?

Muscle strength:
----------------
Do you have loss of muscle strength in the right knee?
do you have loss of muscle strength in the left knee?

Do yopu have muscle wasting or loss in the knees?
if yes, describe:

joint stability
---------------
Is there a history of recurrent subluxation? Do you have a history of dislocations?
Right:
left:

Is there a history of lateral instability? Is your knee unstable side-to-side?
Right:
left:

Is there a history of recurrent effusion? Do you get fluid on your knees?
if yes, describe:

Does the veteran now have or has he or she ever had recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment?

if yes, describe:

Meniscal conditions
--------------------
Does the veteran now have or has he or she ever had a meniscus (semilunar cartilage) condition?
which knee(s)? right left

Surgical procedures
--------------------
Indicate any surgical procedures that the veteran has had performed.
if yes, describe date, facility, procedure:

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 any conditions listed in the diagnosis section above?

if yes, describe:

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:

Diagnostic testing
------------------
Have imaging studies of the knee been performed and are the results available?
if yes, describe including date, study type, facility, results:

Functional impact
-----------------
Regardless of the veteran's current employment status, do the condition(s) listed in the diagnosis section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)?
Functional Impact

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

Describe the history (including onset and course) of the veteran's foot condition (brief summary):

Does the veteran report pain of the foot being evaluated on this dbq?

if yes, document the veteran's description of pain in his or her own words

2c. Does the veteran report that flare-ups impact the function of the foot?

right foot
if yes, document the veteran's description of the flare-ups in his or her own words:

How often do flare-ups occur?

How severe are the flare-ups (mild, moderate, severe)?

How long do the flare-ups last?

Describe what events cause flare-ups to occur (precipitating):

Describe what helps make the flare-ups better (alleviate):

Left foot
if yes, document the veteran's description of the flare-ups in his or her own words:

How often do flare-ups occur?

How severe are the flare-ups (mild, moderate, severe)?

How long do the flare-ups last?

Describe what events cause flare-ups to occur (precipitating):

Describe what helps make the flare-ups better (alleviate):

Has the veteran had foot surgery (arthroscopic or open)?
Indicate any surgical procedures that the veteran has had performed.
if yes, describe date, facility, procedure:

Has the veteran had a foot injury or other painful foot conditions?
if yes, describe the foot injury or other foot conditions (including frequency and physical exam findings) and complete question b (severity and side affected).

Indicate severity and side affected.
Not affected
mild
moderate
moderately severe
severe

Does the foot condition chronically compromise weight bearing?

Does the foot condition require arch supports, custom orthotic inserts or shoe modifications?

does the veteran report having any functional loss or functional impairment of the foot being evaluated on this dbq (regardless of repetitive use)?

if yes, document the veteran's description of functional loss or functional impairment in his or her own words
:

does the veteran have any scars (surgical or otherwise) related to any conditions in the diagnosis section above?

Is there pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when the foot is used repeatedly over a period of time?
Right foot
left foot

Is there any other functional loss during flare-ups or when the foot is used repeatedly over a period of time?

Have imaging studies of the foot been performed and are the results available?
if yes, describe including date, study type, facility, results:

Regardless of the veteran's current employment status, do the condition(s) listed in the diagnosis section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)?
Functional Impact

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

=====================================================================================
===================================================================================== Ankle DBQankle

Describe the history (including onset and course) of the veteran's ankle condition (brief summary):

Does the veteran report pain of the ankle being evaluated on this dbq?

if yes, document the veteran's description of pain in his or her own words

2c. Does the veteran report that flare-ups impact the function of the ankle?

right ankle
if yes, document the veteran's description of the flare-ups in his or her own words:

How often do flare-ups occur?

How severe are the flare-ups (mild, moderate, severe)?

How long do the flare-ups last?

Describe what events cause flare-ups to occur (precipitating):

Describe what helps make the flare-ups better (alleviate):

Left ankle
if yes, document the veteran's description of the flare-ups in his or her own words:

How often do flare-ups occur?

How severe are the flare-ups (mild, moderate, severe)?

How long do the flare-ups last?

Describe what events cause flare-ups to occur (precipitating):

Describe what helps make the flare-ups better (alleviate):

does the veteran report having any functional loss or functional impairment of the ankle being evaluated on this dbq (regardless of repetitive use)?

if yes, document the veteran's description of functional loss or functional impairment in his or her own words:

Does the veteran now have or has he or she ever had "shin splints", stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the veteran had a talectomy (astragalectomy)?
if yes, document the veteran's description:

Has the veteran had ankle surgery (arthroscopic or open)?
Indicate any surgical procedures that the veteran has had performed.
if yes, describe date, side (left or right), facility, procedure:

does the veteran have any scars (surgical or otherwise) related to any conditions in the diagnosis section above?

Is there pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-ups or when the ankle is used repeatedly over a period of time?
Right ankle
left ankle

Is there any other functional loss during flare-ups or when the ankle is used repeatedly over a period of time?

Have imaging studies of the ankle been performed and are the results available?
if yes, describe including date, study type, facility, results:

Regardless of the veteran's current employment status, do the condition(s) listed in the diagnosis section impact his or her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)?
Functional Impact

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

=====================================================================================
=====================================================================================Neurologic Headaches DBQVA Headaches DBQ

What type(s) of headaches does the veteran have (check all that apply)

Migraine including migraine variants Acute/Intermittent Tension Headache, not Chronic Chronic Tension Headache Cluster Other, describe

For each of the above selected, document --
Date of onset:

Details of onset:

Course since onset:

Describe Treatment: list only those medications used for Headache(s) and the Frequency (e.g. daily or PRN) for each:

Does the Veteran experience headache pain?
If yes, check all that apply to headache pain:
Constant head pain Pulsating or throbbing head pain Pain localized to one side of the head Pain on both sides of the head Pain worsens with physical activity Other, describe:

Does the Veteran experience non-headache symptoms associated with headaches? (including symptoms associated with an aura prior to headache pain):
If yes, check all that apply:
Nausea Vomiting Sensitivity to light Sensitivity to sound Changes in Vision (such as scotoma, flashes of light, tunnel vision) Sensory changes (such as feeling of pins and needles in extremities) Other, describe:

Indicate duration of typical head pain:
Less than 1 day 1-2 days More than 2 days Other, describe:

Indicate location of typical head pain:
Right side of head Left side of head Both sides of head Other, describe:

Prostrating Attacks of Headache Pain
Completely prostrating as used by VA in 38 CFR 4.124a, DC8100, means extreme exhaustion or powerless with essentially total inability to engage in ordinary activities.

Migraine/non-migraine: Does the Veteran have characteristic prostrating attacks of migraine/non-migraine headache pain?

If yes, indicate frequency, on average, of prostrating attacks over the last several months:
With less frequent attacks Once in 2 months Once every month

Does the Veteran have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability? E.G. Missing several weeks of work/month

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:

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:

Are there any other significant diagnostic test findings and/or results?

If yes, describe:
Type of test or procedure:

Date of test:

Results (brief summary):

Additional diagnostic test findings and/or results:

Does the Veteran's Headache condition impact his or her ability to work?
Current or if Retired/Unemployed, Previous Occupation:
In last 12 months, how many work days were missed due only to the Headache condition:
0-1 week work time lost in last 12 months 1-2 weeks work time lost in last 12 months 2-4 weeks work time lost in last 12 months >5 weeks work time lost in last 12 months - confirmed in medical record
If yes, describe the functional impact of each condition, providing one or more examples.

===================================================================================== Sleep Apnea DBQ Ear DBQVA ear DBQ

Describe the history (including onset and course) of the veteran's ear or peripheral vestibular conditions (brief summary):
When did this condition begin?
Describe how the condition began (e.G. Injury or illness)?

What were the symptoms when the condition began?

Have you been treated for this condition? If yes, specify past medication, surgery and other types of treatment and describe response to the treatment.

What are your current symptoms?

What is your current treatment? For medication, specify name and dosage.

Describe the impact of the condition on your ability to perform occupational functioning and ordinary activities.

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

does the veteran have any of the following findings, signs, or symptoms attributable to meniere's syndrome (endolymphatic hydrops), a peripheral vestibular condition or another diagnosed condition from section 1?

Hearing impairment with vertigo hearing impairment with attacks of vertigo and cerebellar gait tinnitus, unilateral or bilateral vertigo staggering hearing impairment and/or tinnitus other, describe:

Does the veteran have any of the following findings, signs or symptoms attributable to chronic ear infection, inflammation, cholesteatoma or any of the diagnoses listed in section 1;

swelling (external ear canal) dry and scaly (external ear canal) serous discharge (external ear canal) itching (external ear canal) effusion active suppuration aural polyps hearing impairment and/or tinnitus facial nerves paralysis bone loss of skull (if checked, indicate severity) requiring frequent and prolonged treatment other, describe:

Does the veteran have a benign neoplasm of the ear (other than skin only, such as keloid) that causes any impairment of function?
If yes, describe impairment of function caused by this condition:

Does the veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the diagnosis section?
Is the neoplasm benign malignant

does the veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to the conditions listed in the diagnosis section above?

8b. 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?

8c. Comments, if any:

Have diagnostic imaging studies or other diagnostic procedures been performed?
Magnetic resonance imaging (mri) computerized axial tomography (ct) electronystagmography (eng) other, specify
Date, facility, which limbs? Results?

are there any other significant diagnostic test findings and/or results?
Date, facility, which limbs? Results?

Does the veteran's ear condition impact his or her ability to work?
Current or if retired/unemployed, previous occupation:
in the last 12 months, how many work days were missed due only to the ear condition(s)?
0-1 week work time lost in last 12 months 1-2 weeks work time lost in last 12 months 2-4 weeks work time lost in last 12 months >5 weeks work time lost in last 12 months - confirmed in medical record
describe the impact of the veteran's ear condition, providing one or more examples:

===================================================================================== Peripheral Nerves Conditions DBQPERIPHERAL NERVES CONDITIONS (NOT INCLUDING DIABETIC SENSORY - MOTOR PERIPHERAL NEUROPATHY) DISABILITY BENEFITS QUESTIONNAIRE

For an Original or New Claim:
> How diagnosed (Which doctor/HCP? What tests?)

> Date of diagnosis (approximate date if not recent; e.g., 1/1/90)
> Actual diagnosis

> Any complications

> Current medications and/or treatments (include medication name, dose strength and frequency of use. Don't say only PRN)

> Any doctor prescribed regulation of activities

For an Increase Claim:
> Only interval history required. How has it worsened since last disability exam?

> Current medications and/or treatments (include medication name, dose strength and frequency of use. Don't say only PRN)

> Any doctor prescribed regulation of activities

SECTION II - MEDICAL HISTORY2A.DESCRIBE THE HISTORY (INCLUDING ONSET AND COURSE) OF THE VETERAN’S PERIPHERAL NERVE CONDITIONS (brief summary):

Onset (how did it start?):

Course (what happened after it first started? Is it getting worse? What complications have there been, if any?):

Current Treatment/Frequency (medications, therapy, surgeries. include medication name, dose strength and frequency of use. Don't say only PRN):

indicate symptoms' location and severity

CONSTANT PAIN (MAY BE EXCRUCIATING AT TIMES)
Right upper extremity:
Left upper extremity:
Right lower extremity:
Left lower extremity:
comments

INTERMITTENT PAIN (USUALLY DULL)
Right upper extremity:
Left upper extremity:
Right lower extremity:
Left lower extremity:
comments

PARESTHESIAS AND/OR DYSESTHESIAS (pins and needles)
Right upper extremity:
Left upper extremity:
Right lower extremity:
Left lower extremity:
comments

NUMBNESS
Right upper extremity:
Left upper extremity:
Right lower extremity:
Left lower extremity:
comments

HAVE EMG STUDIES BEEN PERFORMED?
Date, facility, which limbs? Results?

ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
Date, facility, which limbs? Results?

DOES THE VETERAN’S PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY IMPACT HIS OR HER ABILITY TO WORK?
current job, or previous job if retired or unemployed:
Number of days missed due to nerve condition over past year:
describe impact of each of the Veteran’s peripheral nerve and/or peripheral neuropathy condition(s), providing one or more examples:

=====================================================================================Dermatologic Skin DBQVA Skin Conditions DBQ
Describe the history (including onset and course) of the Veteran's skin conditions (brief summary):
Condition 1
Condition:
Location:
Date of onset:
Course:
Condition 2 Condition 3

Resolved Skin conditions-Did the veteran previously have a skin condition that is now completely resolved and no longer requires treatment of any type?
If yes, describe:

Has the Veteran been treated with oral or topical medications in the past 12 months for any skin condition?
If yes, describe:

Has the Veteran had any treatments or procedures other than systemic or topical medications in the past 12 months for any skin condition?
If yes, describe:

Does the veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the diagnosis section?
Is the neoplasm benign or malignant?
(If malignant, indicate status of disease)
Does the veteran currently have any residual conditions or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above?
If yes, describe:

Do any of the veteran's skin conditions cause scarring (regardless of location), or disfigurement of the head, face or neck?

If yes, describe:

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:

functional impact
Does the veteran's skin condition impact his or her ability to work?
Functional Impact

Does the veteran's claimed condition impact his or her ability to work?
========================================================================================
===================================================================================== Scars DBQ (complete if requested, or if veteran has painful, unstable, or extensive scars)Scars DBQ

History for Scars of Trunk or Extremities (Hed, Neck or Face scar history is recorded in another section)
Describe the history (including cause/origin and course) of the veteran's scar(s) of the trunk or extremities (brief summary):
When did this condition begin? (approximate date)
describe how the condition began (e.G. Injury or illness)?

what were the symptoms when the condition began?

have you been treated for this condition? If yes, specify past medication, surgery and other types of treatment and describe response to the treatment.

what are your current symptoms?

what is your current treatment? For medication, specify name and dosage.

describe the impact of the condition on your ability to perform occupational functioning and ordinary activities.

Are any of the scars of the trunk or extremities painful?
If yes, specify the number of painful scars:
Describe the pain (if there are multiple painful scars, be sure to adequately identify which scars are painful):

Are any of the scars of the trunk or extremities unstable, with frequent loss of covering of skin over the scar?
If yes, specify the number of unstable scars:
Describe the loss of covering of skin over the scar (if there are multiple unstable scars, be sure to adequately identify which scars are unstable):

Are any of the scars of the trunk or extremities due to burns?
If yes, identify each burn scar and state depth of original burn:
burn scar 1 burn scar 2 burn scar 3 burn scar 4 burn scar 5

Scars or Other Disfigurement of the Head, Face or Neck
Describe the history (including cause/origin and course) of the veteran's scar(s) or other disfigurement of the head, face or neck (brief summary):
When did this condition begin? (approximate date)
describe how the condition began (e.G. Injury or illness)?

what were the symptoms when the condition began?

have you been treated for this condition? If yes, specify past medication, surgery and other types of treatment and describe response to the treatment.

what are your current symptoms?

what is your current treatment? For medication, specify name and dosage.

describe the impact of the condition on your ability to perform occupational functioning and ordinary activities.

Are any of the scars of head, face, or neck painful?
If yes, specify the number of painful scars:
Describe the pain (if there are multiple painful scars, be sure to adequately identify which scars are painful):

Are any of the scars of head, face, or neck unstable, with frequent loss of covering of skin over the scar?
If yes, specify the number of unstable scars:
Describe the loss of covering of skin over the scar (if there are multiple unstable scars, be sure to adequately identify which scars are unstable):

Are any of the scars of head, face, or neck due to burns?
If yes, identify each burn scar and state depth of original burn:
burn scar 1 burn scar 2 burn scar 3 burn scar 4 burn scar 5

limitation of function/other conditions
Do any of the scars (regardless of location) or disfigurement of the head, face or neck result in limitation of function (to include limitation of motion)?
If yes, indicate which scars (regardless of location) or disfigurement of the head, face or neck are causing the limitation and describe the specific limitations:
Does the veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms (such as muscle or nerve damage) associated with any scar?

functional impact
Does the veteran's scar condition impact his or her ability to work?
Current or if retired/unemployed, previous occupation:
in the last 12 months, how many work days were missed due only to the scar condition(s)?
0-1 week work time lost in last 12 months 1-2 weeks work time lost in last 12 months 2-4 weeks work time lost in last 12 months >5 weeks work time lost in last 12 months - confirmed in medical record
describe the impact of the veteran's scar condition, providing one or more examples:

=====================================================================================Internal Medicine Esophagus DBQESOPHAGUS

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)

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:

if checked, indicate average duration of episodes of symptoms:

material weight loss

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)

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

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

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

if checked, indicate average duration of episodes of vomiting:

hematemesis (vomiting blood)
if checked, indicate frequency of episodes of hematemesis per year:

if checked, indicate average duration of episodes of hematemesis:

melena with moderate anemia
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?
===================================================================================== Other Intestinal Problems DBQ Hepatitis DBQHEPATITIS, CIRRHOSIS AND OTHER LIVER CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE

3A.DOES THE VETERAN CURRENTLY HAVE SIGNS OR SYMPTOMS ATTRIBUTABLE TO CHRONIC OR INFECTIOUS LIVER DISEASES?

If YES, INDICATE SIGNS AND SYMPTOMS ATTRIBUTABLE TO CHRONIC OR INFECTIOUS LIVER DISEASES (check all that apply):
Fatigue Malaise Anorexia Nausea Vomiting Arthralgia Weight loss Right upper quadrant pain Hepatomegaly Condition requires dietary restriction Condition results in other indications of malnutrition Other

3B.HAS THE VETERAN BEEN DIAGNOSED WITH HEPATITIS C?

IF YES, INDICATE RISK FACTORS (check all that apply):
Unknown
No known risk factors
Organ transplant before 1992
Transfusions of blood or blood products before 1992
Hemodialysis
Accidental exposure to blood by health care workers (to include combat medic or corpsman) Intravenous drug use or intranasal cocaine use
High risk sexual activity
Other direct percutaneous exposure to blood (such as by tattooing, body piercing, acupuncture with non-sterile needles, shared toothbrushes and/or shaving razors)
Other

3C.HAS THE VETERAN HAD ANY INCAPACITATING EPISODES (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upperquadrant pain) DUE TO THE LIVER CONDITIONS DURING THE PAST 12 MONTHS?

IF YES, PROVIDE THE TOTAL DURATION OF THE INCAPACITATING EPISODES OVER THE PAST 12 MONTHS:

4A.DOES THE VETERAN CURRENTLY HAVE SIGNS OR SYMPTOMS ATTRIBUTABLE TO CIRRHOSIS OF THE LIVER, BILIARY CIRRHOSIS OR CIRRHOTIC PHASE OF SCLEROSING CHOLANGITIS?

IF YES, INDICATE SIGNS AND SYMPTOMS ATTRIBUTABLE TO CIRRHOSIS OF THE LIVER, BILIARY CIRRHOSIS OR CIRRHOTIC PHASE OF SCLEROSING CHOLANGITIS(check all that apply):
Weakness Anorexia Abdominal pain Malaise
Weight loss
Ascites
Hepatic encephalopathy
Hemorrhage
Portal hypertension
Splenomegaly
Persistent jaundice

SECTION V - LIVER TRANSPLANT AND/OR LIVER INJURY
5A.IS THE VETERAN A LIVER TRANSPLANT CANDIDATE?

5B.IS THE VETERAN CURRENTLY HOSPITALIZED AWAITING TRANSPLANT?

Date of hospital admission for this condition:
5C.HAS THE VETERAN UNDERGONE A LIVER TRANSPLANT?

Date(s) of surgery:
Date of hospital discharge:
Current signs and symptoms:
5D.HAS THE VETERAN HAD AN INJURY TO THE LIVER?

IF YES, DOES THE VETERAN HAVE PERITONEAL ADHESIONS RESULTING FROM AN INJURY TO THE LIVER?

SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS6A.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):
6B.DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THEDIAGNOSIS SECTION ABOVE?

8.DOES THE VETERANS LIVER CONDITION IMPACT HIS OR HER ABILITY TO WORK?

IF YES, DESCRIBE THE IMPACT OF EACH OF THE VETERANS LIVER CONDITIONS, PROVIDING ONE OR MORE EXAMPLES:
===================================================================================== Kidney DBQKIDNEY

SECTION III - RENAL DYSFUNCTION

3.DOES THE VETERAN HAVE RENAL DYSFUNCTION? (Evidence of renal dysfunction includes either persistent proteinuria, hematuria or GFR < 60 cc/min/1.73m2)

(If “YES,” complete the following section):

3A.DOES THE VETERAN REQUIRE REGULAR DIALYSIS?

3B.DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS DUE TO RENAL DYSFUNCTION?

(If “YES,” check all that apply):
Proteinuria (albuminuria)( If checked, indicate frequency:
(check all that apply) Some Transient Slight Persistent
Edema (due to renal dysfunction)(If checked, indicate frequency:(check all that apply) Some Transient Slight Persistent

Anorexia due to renal dysfunction
Weight loss due to renal dysfunction
If checked, provide baseline weight (average weight for 2-year period preceding onset of disease):
Provide current weight:

Generalized poor health due to renal dysfunction
Lethargy due to renal dysfunction
Weakness due to renal dysfunction
Limitation of exertion due to renal dysfunction
Cause:
Date of Onset:
Details of Onset:
Course Since Onset:
Current Symptoms:

Able to perform only sedentary activity, due to persistent edema caused by renal dysfunction
Markedly decreased function of other organ systems, especially the cardiovascular system, caused by renal dysfunction (
If checked, describe):

Other, (
If checked, describe):
3C.DOES THE VETERAN HAVE HYPERTENSION AND/OR HEART DISEASE DUE TO RENAL DYSFUNCTION OR CAUSED BY ANY KIDNEY CONDITION?

(If “Yes,” also complete Hypertension and/or Heart Disease Questionnaire, as appropriate.)3D.IS THE RENAL TUBULAR DISORDER SYMPTOMATIC?

3E.FREQUENT ATTACKS OF COLIC WITH INFECTION (Pyonephrosis)?

If “YES,” indicate severity (checked, all that apply):

No symptoms or attacks of colic
Occasional attacks of colic
Frequent attacks of colic
Causing voiding dysfunction
Requires catheter drainage
Causing infection (pyonephrosis)
Causing urolithiasis
Causing impaired kidney function "]

SECTION IV - UROLITHIASIS4.
DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD KIDNEY, URETAL OR BLADDER CALCULI (Urolithiasis)?

(If “YES,” complete the following section):
4A.INDICATE CURRENT/PAST LOCATION OF CALCULI (Check all that apply)
Kidney
Ureter
Bladder
4B.HAS THE VETERAN HAD TREATMENT FOR RECURRENT STONE FORMATION IN THE KIDNEY, URETER OR BLADDER?

(If “YES,” indicate treatment (check all that apply)):

Diet therapy required
If checked, specify diet and dates of use:

Drug therapy required
If checked, list medication and dates of use:

Invasive or non-invasive procedures
If checked, indicate average number of times per year invasive or non-invasive procedures were required:

0 to 1 per year
2 per year
more than 2 per yearDate and facility of most recent invasive or non-invasive procedure:

4C.DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS DUE TO UROLITHIASIS?

(If “YES,” indicate severity (check all that apply)):

No symptoms or attacks of colic
Occasional attacks of colic
Frequent attacks of colic
Causing voiding dysfunction
If checked, also complete the Urinary Tract Conditions Questionnaire.
Catheter drainage
Drainage required
Drainage not required
Infections
Infections noted
No infections noted
Causing hydronephrosis
Causing impaired kidney function
Other, describe:
SECTION V - INFECTIONS OF THE KIDNEY AND/OR URINARY TRACT5.DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT OR KIDNEY INFECTIONS?

(If “YES,” complete the following section):
5A.ETIOLOGY OF RECURRENT URINARY TRACT OR KIDNEY INFECTIONS:

5B.INDICATE ALL TREATMENT MODALITIES USED FOR RECURRENT URINARY TRACT OR KIDNEY INFECTIONS (CHECK ALL THAT APPLY):

No treatment
Long-term drug therapy
If checked, list medications used and indicate dates for courses of treatment over the past 12 months:

Recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year)
Hospitalization
If checked, indicate frequency of hospitalization:

1 or 2 per year
More than 2 per year
Drainage
If checked, indicate dates when drainage was performed over the past 12 months:

Continuous intensive management required
If checked, indicate types of treatment and medications used over the past 12 months:

Intermittent intensive management required
If checked, indicate types of treatment and medications used over the past 12 months:

Other, describe:

5C.INFECTIONS
Infections noted
No infections notedSECTION VI - KIDNEY TRANSPLANT OR REMOVAL6.HAS THE VETERAN HAD A KIDNEY TRANSPLANT OR REMOVAL?

(If “YES,” complete the following section):

6A.HAS THE VETERAN HAD A KIDNEY REMOVED?

(If “YES,” provide reason):

Kidney donation
Due to disease
Due to trauma or injury
Other, describe:
6B.HAS THE VETERAN HAD A KIDNEY TRANSPLANT?

If “YES,” date of transplant:
Name of treatment facility, date of admission and date of discharge for transplant:
6C.IS THERE NEPHRITIS, INFECTION, OR PATHOLOGY OF THE OTHER KIDNEY?

6D.IS THE REMAINING KIDNEY AFFECTED BY NEPHRITIS, INFECTION, OR OTHER PATHOLOGY?

SECTION VII - TUMORS AND NEOPLASMS7A.DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN THE DIAGNOSIS SECTION?

(If “YES,” complete the following section):

7B.IS THE NEOPLASM
Benign
Malignant
Active
In remission

7C.HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASMOR METASTASES?

; watchful waiting

If "YES," indicate type of treatment the Veteran is currently undergoing or has completed (check all that apply):

Treatment completed; currently in watchful waiting status
Surgery
If checked, describe:
Date(s) of surgery:

Radiation therapyDate of most recent treatment:
Date of completion of treatment or anticipated date of completion:

Antineoplastic chemotherapyDate of most recent treatment:
Date of completion of treatment or anticipated date of completion:

Other therapeutic procedure
If checked, describe procedure:

Date of most recent procedure:

Other therapeutic treatment
If checked, describe treatment:
Date of completion of treatment or anticipated date of completion:

7D.DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM (INCLUDING METASTASES) OR ITSTREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED IN THE REPORT ABOVE?

(If “YES,” list residual conditions and complications (brief summary)):

7E.IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN THE DIAGNOSIS SECTION, DESCRIBE USING THE ABOVE FORMAT:

SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS8A.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):

8B.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?

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Does the veteran have any scars (surgical or othemise) related to any conditions or to the treatment of any conditions listed in the diagnosis section above?

Scars DBQ (complete if requested, or if veteran has painful, unstable, or extensive scars)Scars DBQ

History for Scars of Trunk or Extremities (Hed, Neck or Face scar history is recorded in another section)
Describe the history (including cause/origin and course) of the veteran's scar(s) of the trunk or extremities (brief summary):
When did this condition begin? (approximate date)
describe how the condition began (e.G. Injury or illness)?

what were the symptoms when the condition began?

have you been treated for this condition? If yes, specify past medication, surgery and other types of treatment and describe response to the treatment.

what are your current symptoms?

what is your current treatment? For medication, specify name and dosage.

describe the impact of the condition on your ability to perform occupational functioning and ordinary activities.

Are any of the scars of the trunk or extremities painful?
If yes, specify the number of painful scars:
Describe the pain (if there are multiple painful scars, be sure to adequately identify which scars are painful):

Are any of the scars of the trunk or extremities unstable, with frequent loss of covering of skin over the scar?
If yes, specify the number of unstable scars:
Describe the loss of covering of skin over the scar (if there are multiple unstable scars, be sure to adequately identify which scars are unstable):

Are any of the scars of the trunk or extremities due to burns?
If yes, identify each burn scar and state depth of original burn:
burn scar 1 burn scar 2 burn scar 3 burn scar 4 burn scar 5

Scars or Other Disfigurement of the Head, Face or Neck
Describe the history (including cause/origin and course) of the veteran's scar(s) or other disfigurement of the head, face or neck (brief summary):
When did this condition begin? (approximate date)
describe how the condition began (e.G. Injury or illness)?

what were the symptoms when the condition began?

have you been treated for this condition? If yes, specify past medication, surgery and other types of treatment and describe response to the treatment.

what are your current symptoms?

what is your current treatment? For medication, specify name and dosage.

describe the impact of the condition on your ability to perform occupational functioning and ordinary activities.

Are any of the scars of head, face, or neck painful?
If yes, specify the number of painful scars:
Describe the pain (if there are multiple painful scars, be sure to adequately identify which scars are painful):

Are any of the scars of head, face, or neck unstable, with frequent loss of covering of skin over the scar?
If yes, specify the number of unstable scars:
Describe the loss of covering of skin over the scar (if there are multiple unstable scars, be sure to adequately identify which scars are unstable):

Are any of the scars of head, face, or neck due to burns?
If yes, identify each burn scar and state depth of original burn:
burn scar 1 burn scar 2 burn scar 3 burn scar 4 burn scar 5

limitation of function/other conditions
Do any of the scars (regardless of location) or disfigurement of the head, face or neck result in limitation of function (to include limitation of motion)?
If yes, indicate which scars (regardless of location) or disfigurement of the head, face or neck are causing the limitation and describe the specific limitations:
Does the veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms (such as muscle or nerve damage) associated with any scar?

functional impact
Does the veteran's scar condition impact his or her ability to work?
Current or if retired/unemployed, previous occupation:
in the last 12 months, how many work days were missed due only to the scar condition(s)?
0-1 week work time lost in last 12 months 1-2 weeks work time lost in last 12 months 2-4 weeks work time lost in last 12 months >5 weeks work time lost in last 12 months - confirmed in medical record
describe the impact of the veteran's scar condition, providing one or more examples:

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Result - Copy and paste this output:

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