| [613] | 1 | DVBCGNCK ;ALB/GTS-557/THM-GYNECOLOGICAL EXAM ; 4/29/91 11:31 AM
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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:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
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| 7 | W !?25,HD91,!?22,"Compensation and Pension Examination",! W ?33,"# 0705 Worksheet" S HD7="GYNECOLOGICAL",HD8="For "_HD7 W !?(40-($L(HD9)\2)),HD9,!?(40-($L(HD8)\2)),HD8,!!
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| 8 | W !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,!,"Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",?14,HD7
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| 9 | W !!!!,"Narrative:"
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| 10 | W ?13,"An evaluation of the female reproductive system depends",!?13,"on a complete physical examination, a thorough medical",!
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| 11 | W ?13,"history and all appropriate laboratory studies.",!!
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| 12 | W:$D(CMBN) "Note: " I '$D(CMBN) W "A. Medical history "
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| 13 | S TXT=$S($D(CMBN):"TXT1",1:"TXT2") F AW=0:1 S AX=$T(@TXT+AW) S AY=$P(AX,";;",2) W:AY="END" !! Q:AY="END" W AY,!
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| 14 | I '$D(CMBN) W !!!!!!!!!!!!,"B. Subjective complaints:",!!!!!!!!!!,"C. Objective findings:",!!!!!!!!!! D HD2
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| 15 | W:$D(CMBN) !! 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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| 16 | W !!!?8,"1. Uterus",!!?11,"a. Removal of, complete/imcomplete (if incomplete,",!?14,"state if pregnancy is prevented) -",!!!!!!
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| 17 | W ?11,"b. Prolapse of, complete through vulva/imcomplete -",!!!!!!?11,"c. Displacement of; also identify adhesions and irregular",!?14,"menstruation -",!!!!!!
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| 18 | D:$D(CMBN) HD2 W ?8,"2. Ovaries",!!?11,"a. Removal of both -",!!!!!!?11,"b. Removal of one with or without partial removal",!?14,"of the other -",!!!!!!?11,"c. Atrophy of one or both ovaries, complete -",!!!!!!
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| 19 | W ?8,"3. Rectal and rectovaginal; identify any surgical complications",!?11,"of pregnancy -",!!!!!! D:'$D(CMBN) HD2 W ?8,"4. If a malignant process has been present within the past year,",!
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| 20 | W ?11,"give the date of the last surgical, radiation or chemical",!?11,"therapy -",!!!!!!
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| 21 | W ?8,"5. If a tubercular or other mycobacterial infection has been treated",!?11,"within the past year, give the date of inactivity -",!!!!!!?8,"6. Has a voluntary sterilization procedure been performed? -",!!!!!!
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| 22 | D:$D(CMBN) HD2 W $S($D(CMBN):"B. ",1:"E. "),"Diagnostic/clinical test results:",!!!!!!!!!!,$S($D(CMBN):"C. ",1:"F. "),"Diagnosis:",!!!!!!!!!?25,"Signature: ______________________________",!!?30,"Date: _________________________",!
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| 23 | K LN,LN1,LN2
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| 24 | Q
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| 25 | ;
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| 26 | SETIOF ; ** Set device control var's
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| 27 | D HOME^%ZIS
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| 28 | Q
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| 29 | ;
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| 30 | HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for "_NAME,!,HD8,!!!
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| 31 | Q
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| 32 | TXT2 ;;(it is very important that in claims for establishing
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| 33 | ;;service connection that the past medical history, menstrual history, marital
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| 34 | ;;and pregnancy history and urinary history be as complete as possible):
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| 35 | ;;END
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| 36 | ;
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| 37 | TXT1 ;;In completing the medical history for the primary examination to
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| 38 | ;;which this supplemental examination is attached, it is very important
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| 39 | ;;that in claims for establishing service connection that the past medical
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| 40 | ;;history, menstrual history, marital and pregnancy history and urinary
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| 41 | ;;history be as complete as possible.
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| 42 | ;;END
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