[613] | 1 | DVBCPECK ;ALB/GTS-557/THM-PULMONARY, NOT ELSEWHERE CLASSIFIED ; 6/6/90 8:18 AM
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| 2 | ;;2.7;AMIE;;Apr 10, 1995
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| 3 | EN S DVBAX="For PULMONARY, NOT ELSEWHERE CLASSIFIED"
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| 4 | S PG=1 D:'$D(IOF) SETIOF W:(IOST?1"C-".E) @IOF
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| 5 | W !?22,"Compensation and Pension Examination",!?33,"# 1515 Worksheet",!,?(IOM-$L(DVBAX)\2),DVBAX,!!
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| 6 | W "Name: ",NAME,?45,"SSN: ",SSN,!,?45,"C-number: ",CNUM,!,"Date of exam: ____________________",!!,"Place of exam: ___________________",!!,"Type of Exam: PULMONARY, NOT ELSEWHERE CLASSIFIED",!!
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| 7 | W "Physician's Guide Reference: None",!!,"Narrative:",!!
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| 8 | F I=0:1 S LY=$T(TXT+I) D:LY["TOF" HD2 Q:LY["END" W:LY'["TOF" $P(LY,";;",2),! I $Y>55 D HD2
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| 9 | K I,LY,DVBAX Q
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| 10 | ;
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| 11 | TXT ;;This exam is to handle the balance of currently recognized pulmonary
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| 12 | ;;disorders and to allow for new disorders not yet classified for V.A.
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| 13 | ;;compensation evaluations. The severity of a condition is based upon the
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| 14 | ;;residual disability. If there is a disease process that affects multiple
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| 15 | ;;systems or extremeties, please evaluate each separately.
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| 16 | ;;
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| 17 | ;;
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| 18 | ;;A. Medical history (W/P):
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| 19 | ;;
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| 20 | ;;
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| 21 | ;;
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| 22 | ;;
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| 23 | ;;
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| 24 | ;;
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| 25 | ;;
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| 26 | ;;
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| 27 | ;;
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| 28 | ;;
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| 29 | ;;B. Subjective findings (W/P):
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| 30 | ;;
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| 31 | ;;
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| 32 | ;;
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| 33 | ;;
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| 34 | ;;
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| 35 | ;;
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| 36 | ;;
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| 37 | ;;
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| 38 | ;;
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| 39 | ;;
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| 40 | ;;C. Objective findings (W/P):
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| 41 | ;;TOF
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| 42 | ;;
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| 43 | ;;
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| 44 | ;;D. Evaluation Information for the Rating Board:
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| 45 | ;;
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| 46 | ;;
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| 47 | ;; Residual disability effect on:
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| 48 | ;;
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| 49 | ;;
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| 50 | ;; 1) earning capacity/job performance (F/T):
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| 51 | ;;
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| 52 | ;;
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| 53 | ;;
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| 54 | ;;
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| 55 | ;;
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| 56 | ;;
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| 57 | ;; 2) everyday activities (F/T):
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| 58 | ;;
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| 59 | ;;
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| 60 | ;;
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| 61 | ;;
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| 62 | ;;
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| 63 | ;;
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| 64 | ;;
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| 65 | ;; 3) Is disability constant? (YES/NO):
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| 66 | ;;
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| 67 | ;;
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| 68 | ;;
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| 69 | ;;
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| 70 | ;;
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| 71 | ;;
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| 72 | ;;
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| 73 | ;; 4) If NO, give frequency, length of remissions (F/T):
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| 74 | ;;
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| 75 | ;;
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| 76 | ;;
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| 77 | ;;
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| 78 | ;;
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| 79 | ;;
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| 80 | ;; 5) Acute exacerbations effect on everyday life. (F/T)
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| 81 | ;;TOF
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| 82 | ;;
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| 83 | ;;
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| 84 | ;;E. Diagnosis (W/P):
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| 85 | ;;
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| 86 | ;;
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| 87 | ;;
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| 88 | ;;
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| 89 | ;;
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| 90 | ;;
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| 91 | ;;
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| 92 | ;;
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| 93 | ;;
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| 94 | ;;F. Diagnostic tests (Lab,X-Ray, etc) (W/P):
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| 95 | ;;
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| 96 | ;;
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| 97 | ;;
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| 98 | ;;
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| 99 | ;;
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| 100 | ;;
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| 101 | ;;
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| 102 | ;;
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| 103 | ;;
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| 104 | ;; Signature: ______________________________
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| 105 | ;;
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| 106 | ;; Date: _________________________
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| 107 | ;;END
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| 108 | Q
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| 109 | ;
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| 110 | HD2 S PG=PG+1 W @IOF,!,"Page: ",PG,!!,"Compensation and Pension Exam for "_NAME,!
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| 111 | W "For PULMONARY, NOT ELSEWHERE CLASSIFIED",!!!
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| 112 | Q
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| 113 | ;
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| 114 | SETIOF ; ** Set device control var's
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| 115 | D HOME^%ZIS
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| 116 | Q
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