| 1 | DVBCAOCK ;ALB/GTS-557/THM-AGENT ORANGE/RESIDUALS OF DIOXIN ; 5/21/91 9:56 AM
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| 2 | ;;2.7;AMIE;;Apr 10, 1995
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| 3 | ;
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| 4 | S PG=1,HD91="Department of Veterans Affairs",HD9="Full Exam Worksheet"
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| 5 | EN D:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
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| 6 | W !?25,HD91,!?22,"Compensation and Pension Examination",! W ?33,"# 1710 Worksheet" S HD7="RESIDUALS OF DIOXIN EXPOSURE (AGENT ORANGE)",HD8="For "_HD7 W !?(40-($L(HD9)\2)),HD9,!?(40-($L(HD8)\2)),HD8,!!
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| 7 | W !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,!,"Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
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| 8 | W !!!!,"Narrative: "
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| 9 | S LNS="__________",LX="TXT" F I=1:1 S LY=$T(@LX+I) Q:LY["$END" W ?13,$P(LY,";;",2),!
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| 10 | W !!,"A. Initial data base for possible exposure to toxic chemicals:",!!,"Branch of service: ",LNS,?33,"Service serial number: ",LNS,!!
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| 11 | S X="month/year",Y="from __________ to __________" W "Dates of service:",!?26,X,?40,X,!!,"Last period: ",?21,Y,!!?26,X,?40,X,!!,"Next to last period: ",Y,!!
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| 12 | W "Date of birth: __________",!!,"Marital status: ___ married ___ divorced ___ separated",!!!
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| 13 | W "Did veteran have military service in Vietnam? ___ Yes ___ No",!!,"If yes, list all tours of duty in Vietnam:",!!?7,X,?35,X,!,"From:",?30,"To:",! D HD2
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| 14 | W "Indicate the Corps or area where veteran served in Vietnam:",!!,"I Corps ___ II Corps ___ III Corps ___ IV Corps ___ Sea duty ___",!!,"More than one ___ Don't know ___ Other (specify)",LNS,!!
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| 15 | W "List military units in which veteran served (specify complete",!,"unabbreviated titles such as company, battalion, etc.):",!!!!!
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| 16 | W "B. Veteran's exposure to Agent Orange (indicate one category for",!?5,"each circumstance):",!!?36,"Definitely Probably Not Definitely",!?39,"yes",?50,"yes",?58,"sure",?69,"no",!!
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| 17 | W ?3,"1. Veteran was involved in",!?3,"handling or spraying A.O.",!!?3,"2. Veteran was not directly",!?3,"sprayed but was in a recently",!?3,"sprayed area.",!!
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| 18 | W ?3,"3. Veteran was exposed to",!?3,"herbicides other than A.O.",!!?3,"4. Veteran was directly",!?3,"sprayed with Agent Orange.",!!?3,"5. Veteran ate food or drink",!?3,"that could have been contaminated.",!!!
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| 19 | W !!,"C. Indicate how many exposures the veteran alleges:",!!!,"D. Indicate the nature of each exposure:",! D HD2
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| 20 | W "E. Medical history (include symptoms at time of exposure or",!?4,"later attributed by veteran to exposure):",!!!!!!!,"F. Subjective complaints:",!!!!!!!,"G. Objective findings:",!!
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| 21 | W ?2,"a. Height _____ weight _____ pulse _____ blood pressure _______",!! G ^DVBCAOC1
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| 22 | ;
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| 23 | HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for ",HD7,!,"for ",NAME,!!!
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| 24 | Q
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| 25 | ;
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| 26 | SETIOF ; ** Set device control var's
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| 27 | D HOME^%ZIS
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| 28 | Q
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| 29 | ;
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| 30 | TXT ;
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| 31 | ;;Chloracne or other acneform disease consistant with
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| 32 | ;;chloracne, non-Hodgkins lymphoma, and soft-tissue
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| 33 | ;;sarcomas are presumtive Agent Orange-related
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| 34 | ;;disabilities. Veterans who served in Vietnam and
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| 35 | ;;in the waters offshore are presumed to have been
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| 36 | ;;exposed to Agent Orange and/or other herbicides
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| 37 | ;;which may contain dioxin. Attention should be paid
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| 38 | ;;to examination of the skin, nervous system, muscular
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| 39 | ;;function, liver, kidneys, lymphatic system and mental
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| 40 | ;;status. Questioning should attempt to uncover details
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| 41 | ;;of exposure and any adverse affects.
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| 42 | ;;$END
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