DVBCEXM1 ;ALB/CMC REQUEST WORKSHEET TEXT ; 8/15/97
 ;;2.7;AMIE;**12,16,80**;Apr 10, 1995
 ;
TXT ;
 ;;        Body System:  Musculoskeletal  (DC Series 5000, 5100, 5200, 5300)
 ;;        (    )  Bones (Fractures and Bone Disease)           (    )  Fibromyalgia
 ;;        (    )  Amputation, Residuals of                     (    )  Joints (Shoulder/Elbow/Wrist/Hip/Knee/Ankle)
 ;;        (    )  Hand, Thumb, and Fingers                     (    )  Feet
 ;;        (    )  Spine (Cervical, Thoracic & Lumbar)          (    )  Muscles
 ;;
 ;;        Body System:  Organs of Sense  (DC Series 6000, 6100, 6200)
 ;;        (    )  Eye Examination                              (    )  Audio
 ;;        (    )  Ear Disease                                  (    )  Sense of Smell and Taste
 ;;
 ;;        Body System:  Infectious/Immune/Nutritional  (DC Series 6300)
 ;;        (    )  Infectious, Immune, and Nutritional Disabilities
 ;;        (    )  HIV-Related Illness                          (    )  Chronic Fatigue Syndrome
 ;;
 ;;        Body System:  Respiratory  (DC Series 6500, 6600, 6700, 6800)
 ;;        (    )  Nose, Sinus, Larynx, and Pharynx             (    )  Respiratory (Obstructive, Restrictive,
 ;;        (    )  Pulmonary Tuberculosis and                            and Interstitial)
 ;;                 Mycobacterial Diseases                      (    )  Respiratory Diseases, Miscellaneous
 ;;
 ;;        Body System:  Cardiovascular  (DC Series 7000, 7100)
 ;;        (    )  Arrhythmias                                  (    )  Heart
 ;;        (    )  Arteries, Veins and Miscellaneous            (    )  Hypertension
 ;;
 ;;        Body System:  Digestive  (DC Series 7200, 7300)
 ;;        (    )  Mouth, Lips, and Tongue                      (    )  Esophagus and Hiatal Hernia
 ;;        (    )  Intestines (Large and Small)                 (    )  Liver, Gall Bladder, and Pancreas
 ;;        (    )  Digestive Conditions, Miscellaneous          (    )  Rectum and Anus
 ;;        (    )  Stomach, Duodenum, and Peritoneal Adhesions
 ;;
 ;;        Body System:  Genitourinary  (DC Series 7500)
 ;;        (    )  Genitourinary Examination
 ;;
 ;;        Body System:  Gynecological and Breast  (DC Series 7600)
 ;;        (    )  Gynecological Conditions and 
 ;;                 Disorders of the Breast
 ;;
 ;;        Body System:  Hemic and Lymphatic  (DC Series 7700)
 ;;        (    )  Hemic Disorders                              (    )  Lymphatic Disorders
 ;;
 ;;        Body System:  Skin  (DC Series 7800)
 ;;        (    )  Scars                                        (    )  Skin Diseases (other than scars)
 ;;
 ;;        Body System:  Endocrine  (DC Series 7900)
 ;;        (    )  Endocrine Diseases, Miscellaneous            (    )  Thyroid and Parathyroid Diseases
 ;;        (    )  Cushing's Syndrome                           (    )  Acromegaly
 ;;        (    )  Diabetes Mellitus
 ;;
 ;;        Body System:  Neurologic  (DC Series 8000, 8100, 8200, 8300, 8400, 8500, 8600, 8700, 8800, 8900)
 ;;        (    )  Brain and Spinal Cord                        (    )  Cranial Nerves
 ;;        (    )  Neurological Disorders, Miscellaneous        (    )  Peripheral Nerves
 ;;                                                             (    )  Epilepsy and Narcolepsy
 ;;
 ;;        Body System:  Mental Disorders  (DC Series 9200, 9300, 9400, 9500)
 ;;        (    )  Mental Disorders (not PTSD and Eating Disorders)
 ;;        (    )  Initial Evaluation for Post-Traumatic Stress Disorder (PTSD)
 ;;        (    )  Review Examination for Post-Traumatic Stress Disorder (PTSD)
 ;;        (    )  Eating Disorders (Mental Disorders)
 ;;
 ;;        Body System:  Dental and Oral  (DC Series 9900)
 ;;        (    )  Dental and Oral
 ;;
 ;;        Special Examinations:  
 ;;        (    )  Aid and Attendance or Housebound Examination
 ;;        (    )  Prisoner of War Protocol Examination
 ;;        (    )  Cold Injury Protocol Examination
 ;;        (    )  Gulf War Guidelines
 ;;        (    )  Social and Industrial Survey
 ;;END