| [604] | 1 | English French Notes Complete/Exclude
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| 2 | For CARDIOVASCULAR, NOT ELSEWHERE CLASSIFIED
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| 3 | Type of Exam: CARDIOVASCULAR, NOT ELSEWHERE CLASSIFIED
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| 4 | Physician's Guide Reference: None
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| 5 | Request date
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| 6 | Regional office number
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| 7 | Requester
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| 8 | Priority of exam
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| 9 | Request status
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| 10 | ** No exams selected **
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| 11 | This report will check the 2507 REQUEST file for missing crucial data.
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| 12 | All requests will be checked and those found missing any of the following
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| 13 | will be reported:
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| 14 | 1) Request date
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| 15 | 2) Regional office number
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| 16 | 4) Priority of exam
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| 17 | 5) Request status
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| 18 | 6) Routing location
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| 19 | 7) No exams selected
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| 20 | 8) Requests older than 3 days without C&P Appt links
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| 21 | Enter Y to print the report or N to quit.
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| 22 | 2507 exam integrity report
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| 23 | C & P Exam Integrity Report
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| 24 | Nothing found to report
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| 25 | Social Sec #
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| 26 | Missing items
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| 27 | Enter REASON FOR CANCELLATION:
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| 28 | Cancelled by (M)AS or (R)O? M//
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| 29 | Enter M to indicate cancellation by MAS or
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| 30 | R to indicate cancellation by the Regional Office.
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| 31 | Cancelled by
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| 32 | Unknown source
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| 33 | Enter Y to verify or N to reselect
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| 34 | None - (Request only)
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| 35 | Unknown exam
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| 36 | Cancellation error on
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| 37 | Entire exam is now CANCELLED.
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| 38 | Cancellation error !
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| 39 | An error has occurred during cancellation - bulletin will not be sent!
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| 40 | I am sending a copy of this cancellation to the
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| 41 | cancellation mail group at
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| 42 | since this was transferred in.
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| 43 | 2507 Exam Veteran Selection
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| 44 | 2507 Test Cancellation
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| 45 | Select VETERAN:
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| 46 | Zeroth node for ^DPT record missing!
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| 47 | This request cannot be cancelled entirely because
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| 48 | one or more exams have
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| 49 | been transferred.
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| 50 | been completed.
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| 51 | However, you may cancel other individual exams.
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| 52 | Press RETURN
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| 53 | Do you want to cancel the entire exam
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| 54 | Enter Y to cancel the ENTIRE exam or N to cancel ONLY selected exams
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| 55 | Select EXAM TO CANCEL:
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| 56 | for this
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| 57 | Since all exams have been cancelled
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| 58 | the entire request will be CANCELLED.
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| 59 | for this request:
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| 60 | This exam or request has been
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| 61 | cancelled by the RO
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| 62 | cancelled by MAS
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| 63 | completed, transferred out
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| 64 | Please enter cancellation code
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| 65 | CANCELLED BY
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| 66 | NO '^' ALLOWED AT THIS PROMPT
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| 67 | This is a required response.
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| 68 | CANCELLED BY
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| 69 | Appointment
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| 70 | was not linked to a 2507 request or was
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| 71 | manually rebooked and linked to another appointment.
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| 72 | (If the appointment was manually rebooked, you do not want to auto-rebook.)
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| 73 | If the appointment was not properly linked, it will need to be linked with the
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| 74 | AMIE/C&P appointment link management option.
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| 75 | Hit Return to continue.
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| 76 | This C&P appointment has multiple links with the same Current Appt Date.
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| 77 | Use the AMIE/C&P Appointment Link Management option to review and delete
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| 78 | any duplicate links.
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| 79 | Hit any key to continue.
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| 80 | AMIE C&P Appt Link update
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| 81 | Initial Appt Date:
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| 82 | Current Appt Date:
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| 83 | has been cancelled!
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| 84 | has been cancelled and rebooked for
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| 85 | THE CRANIAL NERVES
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| 86 | 1. Identify the nerve and the side -
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| 87 | 2. Identify the disorder (paralysis, neuritis, neuralgia) -
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| 88 | 3. Describe in detail, quantifying as much as possible, the
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| 89 | motor and sensory impairment. Note if the entire nerve is
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| 90 | affected or only that part of the distribution distal to a
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| 91 | particular localized lesion -
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| 92 | 4. Is tinnitus present? If so is it constant or intermittent? -
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| 93 | HYPERPITUITARISM (CUSHING'S SYNDROME)
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| 94 | 1. Muscular weakness -
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| 95 | 2. Decalcification of bones -
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| 96 | 4. Enlarged sella turcica, pituitary or adrenal glands -
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| 97 | 5. Nervous, cardiovascular or gastrointestinal -
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| 98 | 6. Disease in remission or demonstrably active -
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| 99 | 7. Continuous medication required -
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| 100 | CYSTITIS, BLADDER CALCULUS, RESIDUALS OF BLADDER INJURY,
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| 101 | ALL DISORDERS OF THE PROSTATE, URETHRA AND SURGICAL RESIDUALS (GU)
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| 102 | Complications and/or medical side effects should always be
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| 103 | reported, even when not specifically requested.
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| 104 | 1. Frequency of urination -
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| 105 | 2. Presence or absence of pyuria -
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| 106 | 3. Pain or tenesmus -
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| 107 | 4. Incontinence requiring pads or appliance -
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| 108 | DISEASES OF THE ARTERIES AND VEINS (CARDIOVASCULAR)
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| 109 | Once a diagnosis is established, details about the
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| 110 | permanent medical residuals and how they affect the
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| 111 | veteran's industrial capabilities are very important as
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| 112 | the degree of impairment is used by the rating board to
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| 113 | determine the percentage of disability and payments therefore.
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| 114 | A. Medical history (if a disability is already service connected, then
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| 115 | provide data since last VA rating examination):
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| 116 | 1. Blood pressure -
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| 117 | 3. Skin appearance -
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| 118 | 4. Skin temperature (to the touch) -
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| 119 | 6. Cardiac involvement -
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| 120 | DISEASES/INJURIES OF THE BRAIN
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| 121 | 1. State if a tumor is present. If so, note type and whether
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| 122 | 2. If a malignancy is present but is now cured or in remission,
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| 123 | report the date of last surgery, radiation therapy, chemotherapy
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| 124 | or other treatment -
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| 125 | 3. Describe in detail the motor and sensory impairment of the affected
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| 126 | cranial nerves -
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| 127 | 4. Describe in detail any functional impairment of the peripheral
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| 128 | and autonomic systems -
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| 129 | 5. Describe any psychiatric manifestations in detail -
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| 130 | For DIGESTIVE, NOT ELSEWHERE CLASSIFIED
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| 131 | Type of Exam: DIGESTIVE, NOT ELSEWHERE CLASSIFIED
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| 132 | DISEASES OF THE HEART (CARDIOVASCULAR)
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| 133 | In developing the diagnosis of a cardiac condition, the
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| 134 | NOMENCLATURE AND CRITERIA FOR DIAGNOSIS OF DISEASE
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| 135 | OF THE HEART published by the New York Heart Association
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| 136 | serves as an acceptable standard. If a stress test
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| 137 | could be conducted without cardiovascular contraindications
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| 138 | but physical problems preclude, please state.
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| 139 | 3. X-Ray results -
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| 140 | 4. Stress test (after EKG, if indicated) -
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| 141 | DIABETES INSIPIDUS
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| 142 | 1. Frequency of urination -
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| 143 | 2. Frequency of excessive thirst -
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| 144 | 3. Frequency of syncope -
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| 145 | 4. Blood pressure readings -
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| 146 | 5. Serum osmolality (m Osm/Kg) -
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| 147 | 6. Urine osmolality (m Osm/Kg) -
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| 148 | DIABETES MELLITUS
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| 149 | 1. Frequency of ketoacidosis or hypoglycemic reactions -
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| 150 | 2. Restricted diet and/or regulation of activities -
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| 151 | 3. Loss of weight and strength since last exam -
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| 152 | 4. Anal pruritis -
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| 153 | 5. Vascular deficiencies -
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| 154 | 6. Diabetic ocular disturbances -
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| 155 | 7. Daily insulin requirements (type and amount) -
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| 156 | 8. Blood sugar -
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| 157 | 9. Blood pressure -
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| 158 | 1. Disability effect on everyday activities -
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| 159 | 2. Ancillary problems as a result of the dental condition -
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| 160 | AUDIO-EAR DISEASE
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| 161 | If, in the course of audiometric testing, there is any
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| 162 | indication of ear disease, the veteran should be referred to
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| 163 | a physician for additional exam. Examination should include
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| 164 | inspection of the auricle, the external canal, and tympanic
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| 165 | membranes. Abnormalities in size, shape, or form of the
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| 166 | structure should be noted.
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| 167 | 2. External canal -
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| 168 | 3. Tympanic membrane -
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| 169 | 4. The tympanum -
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| 170 | 5. The mastoid -
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| 171 | 5. State if an active ear disease is present -
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| 172 | 6. State if an infectious disease of the middle or inner
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| 173 | ear is present -
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| 174 | 7. State whether ear disease is affecting any function other
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| 175 | than hearing, such as balance, or is associated with any
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| 176 | upper respiratory disease -
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| 177 | 2507 Exam Data Entry
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| 178 | This request has not been reported to MAS and may not be transcribed.
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| 179 | Select Exam:
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| 180 | This exam is currently being edited. <RETURN> to continue.
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| 181 | These exam results have been electronically signed.
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| 182 | No editing is allowed!
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| 183 | But you may make changes until it is released.
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| 184 | This exam has been transferred to another facility.
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| 185 | DVBA C 2507 EXAM READY
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| 186 | Do you want to print a review copy
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| 187 | Enter Y to print a copy of the results for review
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| 188 | or N to continue editing.
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| 189 | 2507 Review Report
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| 190 | DVBC*
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| 191 | 2507 Request queued for review to device
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| 192 | 1. State the frequency and type of seizures during the past
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| 193 | twelve months, including any change in frequency pattern. If
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| 194 | possible, get the actual number of seizures in each calendar
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| 195 | month. If the veteran keeps a seizure diary, get dates of
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| 196 | 2. If a medical examiner observes any indications of psychiatric
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| 197 | disease associated with epilepsy, a psychiatric consultation
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| 198 | should be ordered.
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| 199 | 2507 Request Inquiry
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| 200 | Date of request:
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| 201 | Enter VETERAN NAME:
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| 202 | C&P Request Inquiry
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| 203 | COMPENSATION AND PENSION EXAM INQUIRY
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| 204 | Res Phone:
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| 205 | Bus Phone:
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| 206 | Exam(s) transferred to another site -- see pending report.
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| 207 | Other Disabilities:
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| 208 | Rated Disability
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| 209 | ESOPHAGUS (DIGESTIVE)
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| 210 | This area of examination is limited to conditions
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| 211 | from mouth to the esophagogastric sphincter.
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| 212 | A. Medical history :
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| 213 | 1. Current weight -
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| 214 | 2. Maximum weight, past year -
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| 215 | 4. Disturbance of motility -
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| 216 | 5. Actual partial obstruction (indicate frequency of dilatation
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| 217 | if required) -
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| 218 | 6. Reflux disturbances -
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| 219 | 7. Presence of pain -
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| 220 | Print Exam Checklist for the Regional Office
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| 221 | A margin of 132 is required for this printout
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| 222 | Print Exam check list
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| 223 | VA Regional Office -
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| 224 | Compensation and Pension Examination Request Worksheet
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| 225 | Veteran's Name: _________________________________________________
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| 226 | VAMC: __________________________
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| 227 | SSN: __________________________
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| 228 | Telephone-Day: _______________________ Night:_______________________ Power of Attorney: _________________
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| 229 | Date Ordered: ____________________________
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| 230 | By: __________________________
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| 231 | Priority of Exam: _________________________ ( ) Insufficient Exam Dated: _______________________
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| 232 | ( ) General Medical Examination ( ) Review of Pertinent Medical Records in
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| 233 | Print Cover Sheet for Fee Exam
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| 234 | Number of copies:
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| 235 | You cannot print less than one or more than ten copies per session.
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| 236 | Fee exam cover sheets should be sent to a printer.
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| 237 | Print C&P Fee Cover Sheet
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| 238 | URETHRAL OR BLADDER FISTULA (GU)
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| 239 | 1. Number and location of fistulae -
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| 240 | 2. Drainage constant or intermittent -
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| 241 | 3. Constant use of pad or appliance -
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| 242 | 4. Frequency of pad changing -
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| 243 | FEET (ORTHOPEDIC)
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| 244 | The findings in each foot will be separately and carefully
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| 245 | described, as this will affect the evaluation. The nomenclature
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| 246 | of toes for examination purposes will be the great toe, the second,
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| 247 | third, fourth and fifth toes, named from the medial or inner side
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| 248 | and which foot is being examined. The functional loss should
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| 249 | be related to the anatomical condition.
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| 250 | 1. Posture (standing, squatting, supination, pronation and
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| 251 | rising on toes and heels) -
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| 252 | 6. Secondary skin and vascular changes -
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| 253 | For GENITOURINARY, NOT ELSEWHERE CLASSIFIED
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| 254 | Type of Exam: GENITOURINARY, NOT ELSEWHERE CLASSIFIED
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| 255 | GENERAL MEDICAL
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| 256 | A. Occupational history (List most current first):
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| 257 | Name/Address of employer Type Monthly Emp dates Time lost
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| 258 | (if unemployed, enter none)
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| 259 | Work Wages from/to Last 12 mo
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| 260 | State if time from employment was lost and give reasons.
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| 261 | B. Medical history (since last rating exam):
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| 262 | C. Present complaints (symptoms only, NOT diagnosis):
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| 263 | D. Examination data:
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| 264 | Temperature:
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| 265 | Time:
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| 266 | AM/PM
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| 267 | Carriage:
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| 268 | Right- or left-handed:
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| 269 | (How determined)
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| 270 | E. Skin, including appendages
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| 271 | F. Lymphatic and hemic systems
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| 272 | G. Head, face and neck:
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| 273 | H. Nose, sinuses, mouth and throat (include gross dental findings):
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| 274 | I. Ears (describe canals, drums, perforations, discharge):
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| 275 | J. Eyes (describe external eye, pupil reaction, movements,
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| 276 | field of vision, any uncorrectable refractive error or
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| 277 | any retinopathy):
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| 278 | K. Cardiovascular system
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| 279 | (describe thrust, size, rhythm, sounds and condition
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| 280 | of peripheral vessels):
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| 281 | Pulse
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| 282 | Blood pressure
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| 283 | Respiration
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| 284 | Sitting
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| 285 | Recumbent
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| 286 | Standing
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| 287 | Sitting after exerc.
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| 288 | 2 min after exercise
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| 289 | L. Varicose veins (describe location, size, extent, ulcers, scars, and
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| 290 | competency of deep circulation):
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| 291 | M. Respiratory system
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| 292 | N. Digestive system
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| 293 | P. Genito-urinary system
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| 294 | Q. Musculo-skeletal system
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| 295 | R. Endocrine system (describe disease of thyroid, pituitary, adrenals
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| 296 | gonads, other body systems affected, etc.):
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| 297 | S. Nervous system
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| 298 | U. Other tests/exams recommended:
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| 299 | V. Diagnostic/clinical test results:
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| 300 | Reviewing Official: ______________________________
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| 301 | An evaluation of the female reproductive system depends
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| 302 | on a complete physical examination, a thorough medical
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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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