| [613] | 1 | DVBCDNCK ;ALB/GTS-557/THM-DENTAL EXAM ; 12/5/90 2:16 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"
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| 5 | S HD9=$S($D(CMBN):"Abbreviated",1:"Full")_" Exam Worksheet"
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| 6 | EN D:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
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| 7 | W !?25,HD91,!?22,"Compensation and Pension Examination",! W ?33,"# 0205 Worksheet" S HD7="DENTAL",HD8="For "_HD7 W !?(40-($L(HD9)\2)),HD9,!?(40-($L(HD8)\2)),HD8,!!
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| 8 | W !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,!,"Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
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| 9 | W !!!!,"Narrative:"
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| 10 | S LX="TXT" F I=1:1 S LY=$T(@LX+I) Q:LY["END" W ?13,$P(LY,";;",2),!
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| 11 | W !! I '$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 ?5,"1. Disability effect on everyday activities -",!!!!!!?5,"2. Ancillary problems as a result of the dental condition -",!!!!!!
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| 14 | W $S($D(CMBN):"B. ",1:"E. "),"Diagnostic/clinical test results:",!!!!!!!!!!!!!! D:$D(CMBN) HD2 W $S($D(CMBN):"C. ",1:"F. "),"Diagnosis:",!!!!!!!!!!!!?25,"Signature: ______________________________",!!?30,"Date: _________________________",!
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| 15 | K LN,LN1,LN2
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| 16 | Q
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| 17 | ;
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| 18 | HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for ",HD7,!,"for ",NAME,!!!
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| 19 | Q
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| 20 | ;
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| 21 | SETIOF ; ** Set device control var's
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| 22 | D HOME^%ZIS
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| 23 | Q
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| 24 | ;
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| 25 | TXT ;
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| 26 | ;;Regional Office action is required for all dental treatment
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| 27 | ;;claims based on combat wounds, service trauma, prisoner of
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| 28 | ;;war or extracted teeth under 38 CFR 17.123.
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| 29 | ;;END
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