| [604] | 1 | English French Notes Complete/Exclude
|
|---|
| 2 | that requires medical follow-up or a problem, which, if treated, may
|
|---|
| 3 | cause a change in hearing threshold levels -
|
|---|
| 4 | Summary of audiologic test results:
|
|---|
| 5 | Recommendations/remarks:
|
|---|
| 6 | Adequated by: ______________________________
|
|---|
| 7 | No exams selected ...
|
|---|
| 8 | Worksheets should be sent to a printer.
|
|---|
| 9 | Print C&P Work Sheets
|
|---|
| 10 | DA*
|
|---|
| 11 | TEMP*
|
|---|
| 12 | Print/Reprint C&P Worksheets
|
|---|
| 13 | Select VETERAN NAME:
|
|---|
| 14 | Select exam(s) to print or enter ALL to print all exams.
|
|---|
| 15 | Select EXAM:
|
|---|
| 16 | Status is not OPEN - No worksheet will be printed.
|
|---|
| 17 | Please select the exams for
|
|---|
| 18 | Use ? to see a list exams available for selection.
|
|---|
| 19 | -- already ON FILE
|
|---|
| 20 | -- Previously cancelled, addition allowable
|
|---|
| 21 | You have not selected any exams.
|
|---|
| 22 | Do you want to try again
|
|---|
| 23 | Enter Y to select more exams or N to abort adding exams to this request.
|
|---|
| 24 | You have selected:
|
|---|
| 25 | Is this exam
|
|---|
| 26 | Are these exams
|
|---|
| 27 | Enter EXAM to delete:
|
|---|
| 28 | Want to add more exams
|
|---|
| 29 | Enter Y to add more exams or N to go on and log existing selections.
|
|---|
| 30 | Another user adding exams now...try again later.
|
|---|
| 31 | PRESS [Return] TO CONTINUE...
|
|---|
| 32 | Do you want to print worksheets
|
|---|
| 33 | Enter Y to print worksheets for items just entered or
|
|---|
| 34 | N to skip.
|
|---|
| 35 | Add a C & P Exam for
|
|---|
| 36 | Veteran Selection
|
|---|
| 37 | Exam selection
|
|---|
| 38 | 2507 Exam Addition
|
|---|
| 39 | This request is a TRANSFER IN and exams cannot be added.
|
|---|
| 40 | This request has been
|
|---|
| 41 | transferred in
|
|---|
| 42 | given an incorrect status
|
|---|
| 43 | Press RETURN
|
|---|
| 44 | Veteran name:
|
|---|
| 45 | Edit Address Information
|
|---|
| 46 | Permanent
|
|---|
| 47 | Temporary:
|
|---|
| 48 | City:
|
|---|
| 49 | State:
|
|---|
| 50 | Zip+4:
|
|---|
| 51 | County:
|
|---|
| 52 | Phone:
|
|---|
| 53 | Office:
|
|---|
| 54 | Do you wish to edit this address:
|
|---|
| 55 | AMIE Package
|
|---|
| 56 | Edit of patient address
|
|---|
| 57 | DVBA C EDIT ADDRESS
|
|---|
| 58 | DVBCML(
|
|---|
| 59 | A bulletin has been sent to the appropriate mail group regarding this
|
|---|
| 60 | address change!
|
|---|
| 61 | ADDR.:
|
|---|
| 62 | City:
|
|---|
| 63 | State:
|
|---|
| 64 | Zip+4:
|
|---|
| 65 | 2. The leg. The stump of an amputated leg will be measured from the insertion
|
|---|
| 66 | of the internal hamstring muscles to the bony end of the stump, with the
|
|---|
| 67 | subject recumbent and the leg flexed at 90 degrees.
|
|---|
| 68 | 3. The arm. The stump of an amputated arm will be measured from the
|
|---|
| 69 | anterior axillary fold to the bony end of the stump, with the stump hanging
|
|---|
| 70 | parallel to the chest wall. Indicate whether the amputation site is above
|
|---|
| 71 | or below the insertion of the deltoid muscle. A statement of the
|
|---|
| 72 | remaining function is the best indicator of a disability's severity.
|
|---|
| 73 | 4. The forearm. The stump of an amputated forearm will be measured from the
|
|---|
| 74 | insertion of the biceps tendon to the bony end, with the elbow flexed
|
|---|
| 75 | at 90 degrees. Indicate if the amputation site is above or below the
|
|---|
| 76 | attachment of the pronator teres.
|
|---|
| 77 | 5. Parts below the wrist. Amputations of fingers will be described as
|
|---|
| 78 | though the distal, middle, or proximal phalanx or as disarticulations through
|
|---|
| 79 | the distal interphalangeal, proximal interphalangeal, or metacarpophalangeal
|
|---|
| 80 | joint. Resection of the head of the metacarpal will always be reported
|
|---|
| 81 | if shown. Complete or partial loss or resection of bones of the hand will
|
|---|
| 82 | described in terms of the fraction of each remaining. If surgery has
|
|---|
| 83 | altered the usefulness of remaining or transplanted digits, this will
|
|---|
| 84 | be described.
|
|---|
| 85 | 6. Parts below the ankle. Complete or partial loss of toes or of
|
|---|
| 86 | metatarsal or tarsal bones will be described as in subparagraph five above.
|
|---|
| 87 | Always report loss of metatarsal head or other defects. Indicate if
|
|---|
| 88 | amputation is through the tarsal-metatarsal joint and if any other portions
|
|---|
| 89 | of the bones of the foot remain.
|
|---|
| 90 | AMPUTATION STUMPS
|
|---|
| 91 | Amputations must be described in accordance with the following
|
|---|
| 92 | b. Amputation above insertion of deltoid muscle
|
|---|
| 93 | c. Amputation below insertion of deltoid muscle
|
|---|
| 94 | a. Above radial insertion of pronator teres (function is best indicator
|
|---|
| 95 | of disability)
|
|---|
| 96 | b. Below insertion of pronator teres
|
|---|
| 97 | a. Disarticulation, with loss of extrinsic pelvic girdle muscles
|
|---|
| 98 | b. Amputation of upper, middle or lower third, always measured
|
|---|
| 99 | from perineum to the boney end of the stump with the claimant
|
|---|
| 100 | recumbent and stump lying parallel with the other lower limb
|
|---|
| 101 | c. State whether this level permits satisfactory prosthesis
|
|---|
| 102 | a. Give level of amputation and condition of stump
|
|---|
| 103 | b. State whether this level permits satisfactory prosthesis
|
|---|
| 104 | c. Describe any stump defects (e.g. painful neuroma or circulatory
|
|---|
| 105 | A. Objective findings:
|
|---|
| 106 | 7. Length of stump (see Attachment A) -
|
|---|
| 107 | 8. Describe any limited motion or instability in
|
|---|
| 108 | the joint above the amputation site -
|
|---|
| 109 | Attachment A
|
|---|
| 110 | Length of stump
|
|---|
| 111 | 1. The thigh. The stump of an amputated thigh will be measured from the
|
|---|
| 112 | perineum, at the origin of the adductor tendons, to the bony end of the stump,
|
|---|
| 113 | with the claimant recumbent and the stump lying parallel with the other
|
|---|
| 114 | lower limb. It is to be kept in mind that if the limb is abducted,
|
|---|
| 115 | flexed, rotated or adducted, its length will be altered. The effective length
|
|---|
| 116 | of a thigh stump is governed by its inside dimension. Measure length of
|
|---|
| 117 | normal thigh if present and indicate whether amputation is in upper,
|
|---|
| 118 | middle, or lower third. When amputation is bilateral, estimate the same
|
|---|
| 119 | for a person of similar height.
|
|---|
| 120 | Processing date:
|
|---|
| 121 | Total pending from previous month:
|
|---|
| 122 | Requests received for date range:
|
|---|
| 123 | Exams returned as insufficient:
|
|---|
| 124 | Requests returned complete:
|
|---|
| 125 | Requests returned incomplete:
|
|---|
| 126 | Total processing time:
|
|---|
| 127 | Pending end of month:
|
|---|
| 128 | Average processing time:
|
|---|
| 129 | Greater than 3 days to schedule:
|
|---|
| 130 | Greater than 30 days to examine:
|
|---|
| 131 | Pending, 0-90 days:
|
|---|
| 132 | Pending, 91-120 days:
|
|---|
| 133 | Pending, 121-150 days:
|
|---|
| 134 | Pending, 151-180 days:
|
|---|
| 135 | Pending, 181-365 days:
|
|---|
| 136 | Pending, 366 or more days:
|
|---|
| 137 | Transfers in from other sites:
|
|---|
| 138 | Transfers returned to other sites:
|
|---|
| 139 | Transfers pending return to other sites:
|
|---|
| 140 | Transfers out to other sites:
|
|---|
| 141 | Transfers returned from other sites:
|
|---|
| 142 | Transfers pending return from other sites:
|
|---|
| 143 | ** Transfer figures are for information only **
|
|---|
| 144 | * and should not be used to balance this report *
|
|---|
| 145 | Bulletin will NOT be sent!!
|
|---|
| 146 | AMIS 290 report for
|
|---|
| 147 | Loading AMIS 290 bulletin ...
|
|---|
| 148 | >> Mail message transmitted <<
|
|---|
| 149 | AMIS 290 Report for
|
|---|
| 150 | For date range:
|
|---|
| 151 | AMIS 290 REPORT
|
|---|
| 152 | Enter STARTING DATE:
|
|---|
| 153 | and ENDING DATE:
|
|---|
| 154 | Invalid date sequence - ending date is before starting date.
|
|---|
| 155 | Please enter the total pending from the previous month:
|
|---|
| 156 | Enter the totals for the month previous to the one you are processing.
|
|---|
| 157 | Must be a number from 0 to 9999.
|
|---|
| 158 | Do you want to send a bulletin when processing is done
|
|---|
| 159 | Enter Y to send a bulletin to selected recipients or N not to send it at all.
|
|---|
| 160 | 2507 Amis Report
|
|---|
| 161 | RO*
|
|---|
| 162 | TOT*
|
|---|
| 163 | DVBCDT(0)
|
|---|
| 164 | XM*
|
|---|
| 165 | For regional office:
|
|---|
| 166 | Requests sent for date range:
|
|---|
| 167 | Exams received incomplete:
|
|---|
| 168 | Exams received complete:
|
|---|
| 169 | Pending for office
|
|---|
| 170 | at end of month:
|
|---|
| 171 | Greater than 5 days to schedule:
|
|---|
| 172 | Greater than 45 days to examine:
|
|---|
| 173 | Press RETURN to continue
|
|---|
| 174 | Regional Office AMIS 290 Report for C&P Examinations
|
|---|
| 175 | Page: 1
|
|---|
| 176 | When selecting regional offices you may enter individual
|
|---|
| 177 | station name or station number.
|
|---|
| 178 | Select REGIONAL OFFICE NUMBER:
|
|---|
| 179 | Want to send a bulletin when processing is done
|
|---|
| 180 | Enter Y to send the bulletin to selected recipients or N not to send it at all.
|
|---|
| 181 | b. Describe the following:
|
|---|
| 182 | 1. General appearance and mental status -
|
|---|
| 183 | 2. Head and neck -
|
|---|
| 184 | H. Indicate whether or not there is evidence of neoplasia in
|
|---|
| 185 | the veteran:
|
|---|
| 186 | I. Indicate whether or not there is evidence of neoplasia in
|
|---|
| 187 | the veteran's family and specify the family member and type
|
|---|
| 188 | of neoplasia, if known:
|
|---|
| 189 | J. Indicate if there is evidence of infertility, spontaneous
|
|---|
| 190 | abortions or teratogenesis in the veteran or the veteran's spouse
|
|---|
| 191 | or immediate family (and describe, if present):
|
|---|
| 192 | K. Indicate if the veteran's spouse or children were in Vietnam
|
|---|
| 193 | (and if so, give details):
|
|---|
| 194 | L. Diagnostic/clinical test results (indicate the results of
|
|---|
| 195 | the following, if performed):
|
|---|
| 196 | a. Complete blood count, including differential -
|
|---|
| 197 | b. Chest X-Ray (if no chest X-Ray within six months) -
|
|---|
| 198 | c. Liver function profile -
|
|---|
| 199 | d. Renal function profile -
|
|---|
| 200 | e. Sperm count -
|
|---|
| 201 | f. Referral to a dermatologist -
|
|---|
| 202 | N. The veteran has been informed of the results of this examination,
|
|---|
| 203 | including X-Ray, blood chemistry, urinalysis, and CBC tests and the
|
|---|
| 204 | following abnormalities were discussed (if none, write
|
|---|
| 205 | Signature of veteran:
|
|---|
| 206 | Examiner's signature:
|
|---|
| 207 | Reviewed by:
|
|---|
| 208 | Environmental Health Physician
|
|---|
| 209 | Full Exam Worksheet
|
|---|
| 210 | RESIDUALS OF DIOXIN EXPOSURE (AGENT ORANGE)
|
|---|
| 211 | Narrative:
|
|---|
| 212 | A. Initial data base for possible exposure to toxic chemicals:
|
|---|
| 213 | Branch of service:
|
|---|
| 214 | Service serial number:
|
|---|
| 215 | Dates of service:
|
|---|
| 216 | Last period:
|
|---|
| 217 | Next to last period:
|
|---|
| 218 | Date of birth: __________
|
|---|
| 219 | Marital status: ___ married ___ divorced ___ separated
|
|---|
| 220 | Did veteran have military service in Vietnam? ___ Yes ___ No
|
|---|
| 221 | If yes, list all tours of duty in Vietnam:
|
|---|
| 222 | Indicate the Corps or area where veteran served in Vietnam:
|
|---|
| 223 | I Corps ___ II Corps ___ III Corps ___ IV Corps ___ Sea duty ___
|
|---|
| 224 | More than one ___ Don't know ___ Other (specify)
|
|---|
| 225 | List military units in which veteran served (specify complete
|
|---|
| 226 | unabbreviated titles such as company, battalion, etc.):
|
|---|
| 227 | B. Veteran's exposure to Agent Orange (indicate one category for
|
|---|
| 228 | each circumstance):
|
|---|
| 229 | Definitely Probably Not Definitely
|
|---|
| 230 | 1. Veteran was involved in
|
|---|
| 231 | handling or spraying A.O.
|
|---|
| 232 | 2. Veteran was not directly
|
|---|
| 233 | sprayed but was in a recently
|
|---|
| 234 | sprayed area.
|
|---|
| 235 | 3. Veteran was exposed to
|
|---|
| 236 | herbicides other than A.O.
|
|---|
| 237 | 4. Veteran was directly
|
|---|
| 238 | sprayed with Agent Orange.
|
|---|
| 239 | 5. Veteran ate food or drink
|
|---|
| 240 | that could have been contaminated.
|
|---|
| 241 | C. Indicate how many exposures the veteran alleges:
|
|---|
| 242 | D. Indicate the nature of each exposure:
|
|---|
| 243 | E. Medical history (include symptoms at time of exposure or
|
|---|
| 244 | later attributed by veteran to exposure):
|
|---|
| 245 | F. Subjective complaints:
|
|---|
| 246 | G. Objective findings:
|
|---|
| 247 | a. Height _____ weight _____ pulse _____ blood pressure _______
|
|---|
| 248 | REGULAR AID AND ATTENDANCE/HOUSEBOUND STATUS
|
|---|
| 249 | D. Present complaints (symptoms only, NOT diagnosis):
|
|---|
| 250 | E. Examination data:
|
|---|
| 251 | Height:
|
|---|
| 252 | Weight:
|
|---|
| 253 | Max wgt past year:
|
|---|
| 254 | Build and state of nutrition:
|
|---|
| 255 | Posture:
|
|---|
| 256 | Gait:
|
|---|
| 257 | General appearance:
|
|---|
| 258 | Pulse:
|
|---|
| 259 | Blood pressure:
|
|---|
| 260 | Respiration:
|
|---|
| 261 | L. Additional remarks as examiner deems necessary in individual case:
|
|---|
| 262 | Compensation and Pension Exam
|
|---|
| 263 | daily services not required
|
|---|
| 264 | HIGHER LEVEL AID & ATTENDANCE
|
|---|
| 265 | BONES (FRACTURES/BONE DISEASE)
|
|---|
| 266 | Type of Exam:
|
|---|
| 267 | Evaluate the effect of functional impairment on gait, posture
|
|---|
| 268 | and specific functions of adjacent joints, muscles and nerves.
|
|---|
| 269 | b. False motion -
|
|---|
| 270 | 3. Intra-articular involvement
|
|---|
| 271 | TRACHEA AND BRONCHI
|
|---|
| 272 | Identify the disease present, describe clinical findings
|
|---|
| 273 | and provide current chest X-Ray results if no recent
|
|---|
| 274 | studies are available. Report pulmonary function studies
|
|---|
| 275 | unless medically contraindicated.
|
|---|
| 276 | 1. Presence of cor pulmonale -
|
|---|
| 277 | 2. If veteran is asthmatic, report frequency of attacks
|
|---|
| 278 | and baseline functional status between attacks -
|
|---|
| 279 | 3. Report any indications of cyanosis/clubbing of extremities -
|
|---|
| 280 | 4. Productive cough/sputum -
|
|---|
| 281 | 5. Dyspnea on exertion/slight exertion/at rest -
|
|---|
| 282 | 6. Indicate whether infectious disease is present -
|
|---|
| 283 | Diagnostic/clincal test results:
|
|---|
| 284 | ==========================< Additional comments >==========================
|
|---|
| 285 | The following veteran had one or more 2507 exams added:
|
|---|
| 286 | Request date:
|
|---|
| 287 | Note: Scheduling for this request must now be recompleted.
|
|---|
| 288 | A new request copy will be printed tomorrow morning.
|
|---|
| 289 | DVBA C EXAM ADDED
|
|---|
| 290 | Bulletin not sent.
|
|---|
| 291 | DVBA C EXAM ADDED mail group not found.
|
|---|
| 292 | Addition of 2507 Exams
|
|---|
| 293 | Cancellation comments:
|
|---|
| 294 | A bulletin will now be sent to the 2507 Cancellation mail group.
|
|---|
| 295 | Exams cancelled Reason
|
|---|
| 296 | *** All exams on this request are now CANCELLED. ***
|
|---|
| 297 | open on this request. ***
|
|---|
| 298 | *** This request is now COMPLETE and should be released by MAS ***
|
|---|
| 299 | DVBA C 2507 CANCELLATION
|
|---|
| 300 | 2507 mail group NOT found! Bulletin not sent.
|
|---|
| 301 | Cancellation of 2507 Exams
|
|---|
| 302 | Undetermined
|
|---|
| 303 | #################### #################### ####################
|
|---|
| 304 | #################### #################### ####################
|
|---|
| 305 | #################### #################### ####################
|
|---|
| 306 | #################### #################### ####################
|
|---|
| 307 | #################### #################### ####################
|
|---|
