| 1 | DVBCGMCK ;ALB/GTS-557/THM-GENERAL MEDICAL EXAM ; 5/16/91 2:20 PM
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| 2 | ;;2.7;AMIE;;Apr 10, 1995
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| 3 | ;
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| 4 | K LINE 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 | S $P(LINE,"-",75)="-"
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| 7 | EN D:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
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| 8 | W !?25,HD91,!?22,"Compensation and Pension Examination",! W ?33,"# 0505 Worksheet" S HD7="GENERAL MEDICAL",HD8="For "_HD7 W !?(40-($L(HD9)\2)),HD9,!?(40-($L(HD8)\2)),HD8,!!
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| 9 | W !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,!,"Date of exam: ____________________",!!,"Place of exam: ___________________"
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| 10 | W !!,"Type of Exam: ",HD7,!!!!,"Narrative:",!!
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| 11 | S TXT="TXT10" D PTXT W !!!,"A. Occupational history (List most current first):",!
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| 12 | W LINE,!,"Name/Address of employer Type Monthly Emp dates Time lost",!,"(if unemployed, enter none)",?29,"Work Wages from/to Last 12 mo",!!!
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| 13 | W "1. ",$E(LINE,2,75),!!,"2. ",$E(LINE,2,75),!!,"3. ",$E(LINE,2,75),!!!,"State if time from employment was lost and give reasons.",!!!?3,$E(LINE,2,75),!!!,"B. Medical history (since last rating exam):",!
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| 14 | D HD2 W "C. Present complaints (symptoms only, NOT diagnosis):",!!!!!!!!!!!!,"D. Examination data:",!!!!,"Height:",?25,"Weight:",?45,"Max wgt past year:",!!!
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| 15 | W "Build and state of nutrition:",!!!,"Temperature:",?23,"Time:",?35,"AM/PM",?50,"Carriage:",!!!,"Posture:",?23,"Gait:",?45,"Right- or left-handed:",!?45,"(How determined)",!!!!!!
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| 16 | W "E. Skin, including appendages " S TXT="TXT2" D PTXT,HD2 W "F. Lymphatic and hemic systems " S TXT="TXT3" D PTXT W !!!!!!!!!!,"G. Head, face and neck:",!!!!!!!!!!
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| 17 | W "H. Nose, sinuses, mouth and throat (include gross dental findings):"
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| 18 | W !! D HD2 W "I. Ears (describe canals, drums, perforations, discharge):",!!!!!!!!,"J. Eyes (describe external eye, pupil reaction, movements,",!
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| 19 | W ?3,"field of vision, any uncorrectable refractive error or",!?3,"any retinopathy):",!!!!!!!!,"K. Cardiovascular system "
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| 20 | W "(describe thrust, size, rhythm, sounds and condition",!," of peripheral vessels):",!!!!!!!!!!!!!!!?25,"Pulse",?39,"Blood pressure",?60,"Respiration",!,LINE,! S LNH="| | |"
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| 21 | W "Sitting",?21,LNH,!,LINE,!,"Recumbent",?21,LNH,!,LINE,!,"Standing",?21,LNH,!,LINE,!,"Sitting after exerc. ",LNH,!,LINE,!,"2 min after exercise ",LNH,!,LINE,! D HD2
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| 22 | W "L. Varicose veins (describe location, size, extent, ulcers, scars, and",!," competency of deep circulation):",!
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| 23 | W !!!!!!,"M. Respiratory system " S TXT="TXT9" D PTXT W !!!!!!!!!,"N. Digestive system " S TXT="TXT4" D PTXT W !!!!!!!!,"O. Hernia" S TXT="TXT5" D PTXT,HD2 W "P. Genito-urinary system " S TXT="TXT6" D PTXT W !
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| 24 | W !!!!!!!!!,"Q. Musculo-skeletal system",!! S TXT="TXT7" D PTXT,HD2 W "R. Endocrine system (describe disease of thyroid, pituitary, adrenals",!?3,"gonads, other body systems affected, etc.):",!!!!!!!!
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| 25 | W "S. Nervous system",!! S TXT="TXT8" D PTXT W !!!!!!!!!!,"T. Remarks:",!!!!!!!!!! D HD2 W "U. Other tests/exams recommended:",!!!!!!!!!!,"V. Diagnostic/clinical test results:",!!!!!!!!!
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| 26 | W "W. Diagnosis:",!!!!!!!!!!!?25,"Signature: ______________________________",!!?30,"Date: _________________________",!
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| 27 | W !!?25,"Signature: ______________________________",!!?30,"Date: _________________________",!
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| 28 | W !!?25,"Signature: ______________________________",!!?30,"Date: _________________________",!
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| 29 | W !!!?16,"Reviewing Official: ______________________________",!!?30,"Date: _________________________",!
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| 30 | K LN,LN1,LN2,LINE
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| 31 | Q
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| 32 | ;
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| 33 | HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam "_HD8_" for ",!,NAME,!!!
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| 34 | Q
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| 35 | ;
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| 36 | PTXT D PTXT^DVBCGMC1
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| 37 | Q
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| 38 | ;
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| 39 | SETIOF ; ** Set device control var's
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| 40 | D HOME^%ZIS
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| 41 | Q
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