| 1 | DVBCNTCK ;ALB/GTS-557/THM-NOSE AND THROAT ; 12/10/90 2:11 PM
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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=$S($D(CMBN):"Abbreviated",1:"Full")_" Exam Worksheet"
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| 5 | EN D:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
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| 6 | W !?25,HD91,!?22,"Compensation and Pension Examination",! W ?33,"# 1510 Worksheet" S HD7="NOSE AND THROAT",HD8="For "_HD7 W !?(40-($L(HD9)\2)),HD9,!?(40-($L(HD8)\2)),HD8,!!
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| 7 | W !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,!,"Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
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| 8 | W !!!!,"Narrative:"
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| 9 | W ?13,"Describe the location and nature of the injury or disease",!?13,"with particular attention to the interference with speech,",!?13,"sense of smell, and/or breathing space. If all or part of the",!?13,"nose is missing provide"
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| 10 | W " photographs. Localize manifestations",!?13,"of chronic sinusitis, if present.",!!!
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| 11 | I '$D(CMBN) W "A. Medical history:",!!!!!!!!!!,"B. Subjective complaints:",!!!!!!!!!!,"C. Objective findings:",! D HD2
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| 12 | W $S($D(CMBN):"A. ",1:"D. "),"Specific evaluation information required by the rating board",!?4,"(if the information requested is included elsewhere, do not",!?4,"repeat here):",!!!
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| 13 | W ?8,"1. Interference with breathing space -",!!!!?8,"2. Headaches, severity, and frequency -",!!!!?8,"3. Purulent discharge -",!!!!
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| 14 | W ?8,"4. Frequency of allergic attacks, baseline status in between -",!
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| 15 | W !!!?8,"5. Dyspnea -",!!!!!!!
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| 16 | D:$D(CMBN) HD2 W $S($D(CMBN):"B. ",1:"E. "),"Diagnostic/clinical test results:",!!!!!!!!!! W $S($D(CMBN):"C. ",1:"F. "),"Diagnosis:",!!!!!!!!!!?25,"Signature: ______________________________",!!?30,"Date: _________________________",!
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| 17 | K LN,LN1,LN2
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| 18 | Q
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| 19 | ;
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| 20 | HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for ",HD7," for ",!,NAME,!!!
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| 21 | Q
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| 22 | ;
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| 23 | SETIOF ; ** Set device control var's
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| 24 | D HOME^%ZIS
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| 25 | Q
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