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