source: FOIAVistA/trunk/r/AUTOMATED_MED_INFO_EXCHANGE-DVBA-DVBC/DVBCAOCK.m@ 1757

Last change on this file since 1757 was 628, checked in by George Lilly, 15 years ago

initial load of FOIAVistA 6/30/08 version

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1DVBCAOCK ;ALB/GTS-557/THM-AGENT ORANGE/RESIDUALS OF DIOXIN ; 5/21/91 9:56 AM
2 ;;2.7;AMIE;;Apr 10, 1995
3 ;
4 S PG=1,HD91="Department of Veterans Affairs",HD9="Full Exam Worksheet"
5EN D:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
6 W !?25,HD91,!?22,"Compensation and Pension Examination",! W ?33,"# 1710 Worksheet" S HD7="RESIDUALS OF DIOXIN EXPOSURE (AGENT ORANGE)",HD8="For "_HD7 W !?(40-($L(HD9)\2)),HD9,!?(40-($L(HD8)\2)),HD8,!!
7 W !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,!,"Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
8 W !!!!,"Narrative: "
9 S LNS="__________",LX="TXT" F I=1:1 S LY=$T(@LX+I) Q:LY["$END" W ?13,$P(LY,";;",2),!
10 W !!,"A. Initial data base for possible exposure to toxic chemicals:",!!,"Branch of service: ",LNS,?33,"Service serial number: ",LNS,!!
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,!!
12 W "Date of birth: __________",!!,"Marital status: ___ married ___ divorced ___ separated",!!!
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
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,!!
15 W "List military units in which veteran served (specify complete",!,"unabbreviated titles such as company, battalion, etc.):",!!!!!
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",!!
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.",!!
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.",!!!
19 W !!,"C. Indicate how many exposures the veteran alleges:",!!!,"D. Indicate the nature of each exposure:",! D HD2
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:",!!
21 W ?2,"a. Height _____ weight _____ pulse _____ blood pressure _______",!! G ^DVBCAOC1
22 ;
23HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for ",HD7,!,"for ",NAME,!!!
24 Q
25 ;
26SETIOF ; ** Set device control var's
27 D HOME^%ZIS
28 Q
29 ;
30TXT ;
31 ;;Chloracne or other acneform disease consistant with
32 ;;chloracne, non-Hodgkins lymphoma, and soft-tissue
33 ;;sarcomas are presumtive Agent Orange-related
34 ;;disabilities. Veterans who served in Vietnam and
35 ;;in the waters offshore are presumed to have been
36 ;;exposed to Agent Orange and/or other herbicides
37 ;;which may contain dioxin. Attention should be paid
38 ;;to examination of the skin, nervous system, muscular
39 ;;function, liver, kidneys, lymphatic system and mental
40 ;;status. Questioning should attempt to uncover details
41 ;;of exposure and any adverse affects.
42 ;;$END
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