| [613] | 1 | DVBCHDCK ;ALB ISC/THM-HYPOTHYROIDISM ; 12/26/90 12:39 PM
|
|---|
| 2 | ;;2.7;AMIE;;Apr 10, 1995
|
|---|
| 3 | ;
|
|---|
| 4 | S PG=1,HD91="Department of Veterans Affairs",HD9=$S($D(CMBN):"Abbreviated",1:"Full")_" Exam Worksheet"
|
|---|
| 5 | EN D:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
|
|---|
| 6 | W !?25,HD91,!?22,"Compensation and Pension Examination",! W ?33,"# 0430 Worksheet" S HD7="HYPOTHYROIDISM",HD8="For "_HD7 W !?(40-($L(HD9)\2)),HD9,!?(40-($L(HD8)\2)),HD8,!!
|
|---|
| 7 | W !,"Name: ",NAME,?45,"SSN: ",SSN,!?45,"C-number: ",CNUM,!,"Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: ",HD7
|
|---|
| 8 | W !!!!,"Narrative:"
|
|---|
| 9 | S LX="TXT" F I=1:1 S LY=$T(@LX+I) Q:LY["END" W ?13,$P(LY,";;",2),!
|
|---|
| 10 | W !! I '$D(CMBN) W "A. Medical history:",!!!!!!!!!!,"B. Subjective complaints:",!!!!!!!!!!,"C. Objective findings:" D HD2
|
|---|
| 11 | 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):",!!!
|
|---|
| 12 | W ?5,"1. Fatigability -",!!!!!!?5,"2. Nervous, cardiovascular, or gastrointestinal symptoms -",!!!!!!?5,"3. Decreased T4 and/or T3 readings -",!!!!!!
|
|---|
| 13 | W ?5,"4. Mental assessment -",!!!!!!?5,"5. Continuous medication required -",!!!!!!
|
|---|
| 14 | W ?5,"6. Myxedema -",!!!!!! D:$D(CMBN) HD2 W ?5,"7. Disease in remission or demonstrably active -",!!!!!! D:'$D(CMBN) HD2
|
|---|
| 15 | W $S($D(CMBN):"B. ",1:"E. "),"Diagnostic/clinical test results:",!!!!!!!!!!!!!!,$S($D(CMBN):"C. ",1:"F. "),"Diagnosis:",!!!!!!!!!!!!?25,"Signature: ______________________________",!!?30,"Date: _________________________",!
|
|---|
| 16 | K LN,LN1,LN2
|
|---|
| 17 | Q
|
|---|
| 18 | ;
|
|---|
| 19 | HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for ",HD7,!,"for ",NAME,!!!
|
|---|
| 20 | Q
|
|---|
| 21 | ;
|
|---|
| 22 | SETIOF ; ** Set device control var's
|
|---|
| 23 | D HOME^%ZIS
|
|---|
| 24 | Q
|
|---|
| 25 | ;
|
|---|
| 26 | TXT ;
|
|---|
| 27 | ;;When symptoms interfere with normal daily activities or job
|
|---|
| 28 | ;;efficiency, it is essential that the extent of such handicaps
|
|---|
| 29 | ;;be described.
|
|---|
| 30 | ;;END
|
|---|
