source: internationalization/trunk/TranslationSpreadsheets/WV-DIALOG-0054.txt@ 1042

English French  Notes   Complete/Exclude
that requires medical follow-up or a problem, which, if treated, may                    
cause a change in hearing threshold levels -                    
Summary of audiologic test results:                     
Recommendations/remarks:                        
Adequated by: ______________________________                    
No exams selected ...                   
Worksheets should be sent to a printer.                 
Print C&P Work Sheets                   
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TEMP*                   
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Select exam(s) to print or enter ALL to print all exams.                        
Select EXAM:                    
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Add a C & P Exam for                    
Veteran Selection                       
Exam selection                  
2507 Exam Addition                      
This request is a TRANSFER IN and exams cannot be added.                        
This request has been                   
transferred in                  
given an incorrect status                       
Press RETURN                            
Veteran name:                   
Edit Address Information                        
Permanent                       
Temporary:                      
City:                   
State:                  
Zip+4:                  
County:                 
Phone:                  
Office:                 
Do you wish to edit this address:                       
AMIE Package                    
Edit of patient address                 
DVBA C EDIT ADDRESS                     
DVBCML(                 
A bulletin has been sent to the appropriate mail group regarding this                   
address change!                 
ADDR.:                          
City:                           
State:                          
Zip+4:                          
 2. The leg.  The stump of an amputated leg will be measured from the insertion                 
of the internal hamstring muscles to the bony end of the stump, with the                        
subject recumbent and the leg flexed at 90 degrees.                     
 3. The arm.  The stump of an amputated arm will be measured from the                   
anterior axillary fold to the bony end of the stump, with the stump hanging                     
parallel to the chest wall.  Indicate whether the amputation site is above                      
or below the insertion of the deltoid muscle.  A statement of the                       
remaining function is the best indicator of a disability's severity.                    
 4. The forearm.  The stump of an amputated forearm will be measured from the                   
insertion of the biceps tendon to the bony end, with the elbow flexed                   
at 90 degrees.  Indicate if the amputation site is above or below the                   
attachment of the pronator teres.                       
 5. Parts below the wrist.  Amputations of fingers will be described as                 
though the distal, middle, or proximal phalanx or as disarticulations through                   
the distal interphalangeal, proximal interphalangeal, or metacarpophalangeal                    
joint.  Resection of the head of the metacarpal will always be reported                 
if shown.  Complete or partial loss or resection of bones of the hand will                      
described in terms of the fraction of each remaining.  If surgery has                   
altered the usefulness of remaining or transplanted digits, this will                   
be described.                   
 6. Parts below the ankle.  Complete or partial loss of toes or of                      
metatarsal or tarsal bones will be described as in subparagraph five above.                     
Always report loss of metatarsal head or other defects.  Indicate if                    
amputation is through the tarsal-metatarsal joint and if any other portions                     
of the bones of the foot remain.                        
AMPUTATION STUMPS                       
Amputations must be described in accordance with the following                  
b. Amputation above insertion of deltoid muscle                 
c. Amputation below insertion of deltoid muscle                 
a. Above radial insertion of pronator teres (function is best indicator                 
of disability)                  
b. Below insertion of pronator teres                    
a. Disarticulation, with loss of extrinsic pelvic girdle muscles                        
b. Amputation of upper, middle or lower third, always measured                  
from perineum to the boney end of the stump with the claimant                   
recumbent and stump lying parallel with the other lower limb                    
c. State whether this level permits satisfactory prosthesis                     
a. Give level of amputation and condition of stump                      
b. State whether this level permits satisfactory prosthesis                     
c. Describe any stump defects (e.g. painful neuroma or circulatory                      
A. Objective findings:                  
7. Length of stump (see Attachment A) -                 
8. Describe any limited motion or instability in                        
the joint above the amputation site -                   
Attachment A                    
Length of stump                 
 1. The thigh.  The stump of an amputated thigh will be measured from the                       
perineum, at the origin of the adductor tendons, to the bony end of the stump,                  
with the claimant recumbent and the stump lying parallel with the other                 
lower limb.  It is to be kept in mind that if the limb is abducted,                     
flexed, rotated or adducted, its length will be altered.  The effective length                  
of a thigh stump is governed by its inside dimension.  Measure length of                        
normal thigh if present and indicate whether amputation is in upper,                    
middle, or lower third.  When amputation is bilateral, estimate the same                        
for a person of similar height.                 
Processing date:                        
Total pending from previous month:                      
Requests received for date range:                       
Exams returned as insufficient:                         
Requests returned complete:                     
Requests returned incomplete:                   
Total processing time:                  
Pending end of month:                   
Average processing time:                        
Greater than 3 days to schedule:                        
Greater than 30 days to examine:                        
Pending, 0-90 days:                     
Pending, 91-120 days:                   
Pending, 121-150 days:                  
Pending, 151-180 days:                  
Pending, 181-365 days:                  
Pending, 366 or more days:                      
Transfers in from other sites:                  
Transfers returned to other sites:                      
Transfers pending return to other sites:                        
Transfers out to other sites:                   
Transfers returned from other sites:                    
Transfers pending return from other sites:                      
 ** Transfer figures are for information only **                        
* and should not be used to balance this report *                       
Bulletin will NOT be sent!!                     
AMIS 290 report for                     
Loading AMIS 290 bulletin ...                   
>> Mail message transmitted <<                  
AMIS 290 Report for                     
For date range:                         
AMIS 290 REPORT                 
Enter STARTING DATE:                    
    and ENDING DATE:                    
Invalid date sequence - ending date is before starting date.                    
Please enter the total pending from the previous month:                         
Enter the totals for the month previous to the one you are processing.                  
Must be a number from 0 to 9999.                        
Do you want to send a bulletin when processing is done                  
Enter Y to send a bulletin to selected recipients or N not to send it at all.                   
2507 Amis Report                        
RO*                     
TOT*                    
DVBCDT(0)                       
XM*                     
For regional office:                    
Requests sent for date range:                   
Exams received incomplete:                      
Exams received complete:                        
Pending for office                      
 at end of month:                       
Greater than 5 days to schedule:                        
Greater than 45 days to examine:                        
Press RETURN to continue                        
Regional Office AMIS 290 Report for C&P Examinations                    
Page: 1                 
When selecting regional offices you may enter individual                        
station name or station number.                 
Select REGIONAL OFFICE NUMBER:                  
Want to send a bulletin when processing is done                 
Enter Y to send the bulletin to selected recipients or N not to send it at all.                 
b. Describe the following:                      
1.  General appearance and mental status -                      
2.  Head and neck -                     
H.  Indicate whether or not there is evidence of neoplasia in                   
the veteran:                    
I.  Indicate whether or not there is evidence of neoplasia in                   
the veteran's family and specify the family member and type                     
of neoplasia, if known:                 
J.  Indicate if there is evidence of infertility, spontaneous                   
abortions or teratogenesis in the veteran or the veteran's spouse                       
or immediate family (and describe, if present):                 
K.  Indicate if the veteran's spouse or children were in Vietnam                        
(and if so, give details):                      
L.  Diagnostic/clinical test results (indicate the results of                   
the following, if performed):                   
a.  Complete blood count, including differential -                      
b.  Chest X-Ray (if no chest X-Ray within six months) -                 
c.  Liver function profile -                    
d.  Renal function profile -                    
e.  Sperm count -                       
f.  Referral to a dermatologist -                       
N.  The veteran has been informed of the results of this examination,                   
including X-Ray, blood chemistry, urinalysis, and CBC tests and the                     
following abnormalities were discussed (if none, write                  
Signature of veteran:                   
Examiner's signature:                   
Reviewed by:                    
Environmental Health Physician                  
Full Exam Worksheet                     
RESIDUALS OF DIOXIN EXPOSURE (AGENT ORANGE)                     
Narrative:                      
A.  Initial data base for possible exposure to toxic chemicals:                 
Branch of service:                      
Service serial number:                  
Dates of service:                       
Last period:                    
Next to last period:                    
Date of birth: __________                       
Marital status: ___ married ___ divorced ___ separated                  
Did veteran have military service in Vietnam? ___ Yes  ___ No                   
If yes, list all tours of duty in Vietnam:                      
Indicate the Corps or area where veteran served in Vietnam:                     
I Corps ___ II Corps ___ III Corps ___ IV Corps ___ Sea duty ___                        
More than one ___ Don't know ___ Other (specify)                        
List military units in which veteran served (specify complete                   
unabbreviated titles such as company, battalion, etc.):                 
B.  Veteran's exposure to Agent Orange (indicate one category for                       
each circumstance):                     
Definitely  Probably  Not    Definitely                 
1. Veteran was involved in                      
handling or spraying A.O.                       
2. Veteran was not directly                     
sprayed but was in a recently                   
sprayed area.                   
3. Veteran was exposed to                       
herbicides other than A.O.                      
4. Veteran was directly                 
sprayed with Agent Orange.                      
5. Veteran ate food or drink                    
that could have been contaminated.                      
C.  Indicate how many exposures the veteran alleges:                    
D.  Indicate the nature of each exposure:                       
E.  Medical history (include symptoms at time of exposure or                    
later attributed by veteran to exposure):                       
F.  Subjective complaints:                      
G.  Objective findings:                 
a. Height _____ weight _____ pulse _____ blood pressure _______                 
REGULAR AID AND ATTENDANCE/HOUSEBOUND STATUS                    
D. Present complaints (symptoms only, NOT diagnosis):                   
E. Examination data:                    
Height:                 
Weight:                 
Max wgt past year:                      
Build and state of nutrition:                   
Posture:                        
Gait:                   
General appearance:                     
Pulse:                  
Blood pressure:                 
Respiration:                    
L. Additional remarks as examiner deems necessary in individual case:                   
Compensation and Pension Exam                   
daily services not required                     
HIGHER LEVEL AID & ATTENDANCE                   
BONES (FRACTURES/BONE DISEASE)                  
Type of Exam:                   
Evaluate the effect of functional impairment on gait, posture                   
and specific functions of adjacent joints, muscles and nerves.                  
b. False motion -                       
3. Intra-articular involvement                  
TRACHEA AND BRONCHI                     
Identify the disease present, describe clinical findings                        
and provide current chest X-Ray results if no recent                    
studies are available.  Report pulmonary function studies                       
unless medically contraindicated.                       
1. Presence of cor pulmonale -                  
2. If veteran is asthmatic, report frequency of attacks                 
and baseline functional status between attacks -                        
3. Report any indications of cyanosis/clubbing of extremities -                 
4. Productive cough/sputum -                    
5. Dyspnea on exertion/slight exertion/at rest -                        
6. Indicate whether infectious disease is present -                     
Diagnostic/clincal test results:                        
==========================<  Additional comments  >==========================                   
The following veteran had one or more 2507 exams added:                 
     Request date:                      
Note:  Scheduling for this request must now be recompleted.                     
       A new request copy will be printed tomorrow morning.                     
DVBA C EXAM ADDED                       
Bulletin not sent.                      
DVBA C EXAM ADDED mail group not found.                 
Addition of 2507 Exams                  
Cancellation comments:                  
A bulletin will now be sent to the 2507 Cancellation mail group.                        
Exams cancelled                               Reason                    
 *** All exams on this request are now CANCELLED. ***                   
 open on this request. ***                      
 *** This request is now COMPLETE and should be released by MAS ***                     
DVBA C 2507 CANCELLATION                        
2507 mail group NOT found!  Bulletin not sent.                  
Cancellation of 2507 Exams                      
Undetermined                    
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