English French Notes Complete/Exclude MISCELLANEOUS NEUROLOGICAL DISORDERS For MUSCULOSKELETAL, NOT ELSEWHERE CLASSIFIED Type of Exam: MUSCULOSKELETAL, NOT ELSEWHERE CLASSIFIED This 2507 already has appointments. Enter '?' for help Is this appointment due to a cancellation? Enter NO if the appointment is not a reschedule of another appointment made previously. Enter YES if the appointment is being scheduled because an appointment has been or will be canceled. '^' NOT ALLOWED You have not selected the linked appointment being rescheduled. You may need to adjust the link to the appointment with the AMIE link management option to ensure proper processing time calculation for this 2507. Enter Yes if the veteran requested a reschedule or 'No Showed' the appointment Enter No if the Clinic required a reschedule. Is this appointment due to a veteran requested cancellation or 'No Show' You have not indicated if the reschedule was due to action by the veteran. The new appointment will not be linked. You will need to adjust the link for this appointment with the AMIE/C&P appointment link management option to ensure proper processing time calculation for this 2507. Remember to cancel the appointment for and do NOT auto-rebook. Hit Return to continue Currently: You have not selected a 2507 request to link the C&P appointment to. The appointment should be linked with the AMIE/C&P Appointment Link Management Option to ensure proper processing time calculation for this 2507 in the event of a veteran cancellation. You have made a C&P appointment for a patient who has no pending 2507 request! Adding new C&P appointment link for 2507 request dated Adjusting C&P appointment link for 2507 request dated MALIGNANCIES OR TUBERCULOSIS (GU) 1. Disease active or inactive - 2. If inactive, date last treatment or date determined inactive - 3. Assess clinical findings - 4. Assess laboratory findings - Narrative: NONE A. Medical history (note history of augmentation mammoplasty with prosthetic implant or reduction mammoplasty): 1. Axillary glands removal - 2. Size of scar - 3. Fixation of scar - 4. Contour of scar - 5. Muscle loss - 6. Tenderness of scar - 7. Nerve damage - 8. Presence of aching, pain or limited use of upper extremeties - 9. Note whether active malignant process is present - 10. If malignancy is inactive, state date of last surgical, radiation or chemical treatment - MENTAL DISORDERS A. Medical and occupational history D. Specific evaluation information required by the rating board E. Diagnostic tests (including psychological testing if deemed necessary): For MENTAL, NOT ELSEWHERE CLASSIFIED Type of Exam: MENTAL, NOT ELSEWHERE CLASSIFIED MUSCLES (ORTHOPEDIC) 1. Tissue loss comparison - 2. Muscles penetrated - 3. Scar formation measurement (sensitiveness, tenderness) - 5. Damage to tendons - 6. Damage to bones, joints, nerves - 8. Evidence of pain - 9. Evidence of muscle hernia - MOUTH AND THROAT All pertinent data must be recorded in the history in order that the otolaryngological change discovered may be correlated with evidence of disease found in other systems of the 1. Oral cavity - 5. Pyriform fossae - Type of Exam: NEPHROLOGICAL 1. Report presence or absence of calculi - 2. If stone, presence and size if retained - 3. Frequency of attacks of colic - 4. Catheter drainage requirments, including frequency - 5. Presence or absence of infection - 6. Involvement of other kidney - INTESTINE (DIGESTIVE) in the portion of this examination is critical to the degree of disability assigned for the 3. Is the veteran anemic? - 6. Diarrhea and/or constipation - 7. Bowel disturbance - 8. Abdominal disturbance - NECK, ABNORMALITIES OF, NOT RESULT OF INJURY OR BONE DISEASE The report of examination should include any abnormal position of the head, range of motion of the head, evidence of paralysis of the neck muscles, and asymmetry produced by abnormal swelling or masses. 1. Range of motion - , NOT ELSEWHERE CLASSIFIED 1) How does the residual disability affect the earning capacity of the veteran in job performance? 2) How does the residual disability affect normal everyday activities? 3) If the disability has constant activity, are there any periods of remission during the year? 4) If there are acute exacerbations, what effects are there on everyday life? Compensation and Pension Exam for For NEUROLOGICAL, NOT ELSEWHERE CLASSIFIED Type of Exam: NEUROLOGICAL, NOT ELSEWHERE CLASSIFIED NEPHRITIS, EXCEPT CHRONIC PYELONEPHRITIS 2. Presence or absence of albumin casts - 4. Red blood cells - 5. Retention of non-protein nitrogen, creatinine or urea nitrogen - 6. Describe overall impairment of kidney function - 7. Report presence or absence of any cardiac complications - Diagnosic/clinical test results: NOSE AND SINUS Report both functional and cosmetic impairment. 1. External nose - 2. Nasal vestibule - 3. Right and left nasal cavities - b. Floor of the nose - c. Inferior meatus - d. Inferior turbinates - e. The middle meati - f. The middle turbinate - g. The spheno-ethmoidal recess - h. The olfactory area - i. The superior turbinates - 4. The paranasal sinuses- NOSE AND THROAT Describe the location and nature of the injury or disease with particular attention to the interference with speech, sense of smell, and/or breathing space. If all or part of the nose is missing provide photographs. Localize manifestations of chronic sinusitis, if present. 1. Interference with breathing space - 2. Headaches, severity, and frequency - 3. Purulent discharge - 4. Frequency of allergic attacks, baseline status in between - 2507 Exams Not Scheduled Within Three Days Enter STARTING DATE REPORTED TO MAS: and ENDING DATE REPORTED TO MAS: 2507 Requests Not Scheduled in Three Days at A right margin of 132 is required for this output! 2507 exams not scheduled in 3 days SDATE* HD* Total requests: patient file record missing Date reported-MAS Date scheduled Requested by For NEPHROLOGICAL, NOT ELSEWHERE CLASSIFIED Type of Exam: NEPHROLOGICAL, NOT ELSEWHERE CLASSIFIED For ORGANS OF SENSE, NOT ELSEWHERE CLASSIFIED Type of Exam: ORGANS OF SENSE, NOT ELSEWHERE CLASSIFIED Additional Veteran Information Is this the correct Veteran Enter Y if it is the correct Veteran, N to reselect Edit Veteran Data Want to edit it again Enter Y to edit the information again or N to skip. 1,5,0,2,0^...Error, required information missing!.... 0,7,0,1:2,0^...Unable to complete, Request aborted!..... DVBA C NEW C&P VETERAN PULMONARY TUBERCULOSIS AND MYCOBACTERIAL DISEASES Is pulmonary tuberculosis or other mycobacterial disease active? If so, identify the organism. In reactivated cases, it is necessary to know whether this is reactivation of the old disease or a separate and distinct new infection. 1. IN ALL CASES: a. Date of inactivity - b. Extent of structural damage to lungs - c. Provide pulmonary function studies - 2. In PENSION CASES ONLY: a. Disease condition after six months of treatment - b. Disease condition after twelve months of treatment - Additional note to the physician: In all claims, if the disease is inactive and if the inactivity was confirmed at a non-VA facility, obtain the name and mailing address of the facility from the veteran so that the Regional Office may request the report. For PULMONARY, NOT ELSEWHERE CLASSIFIED Type of Exam: PULMONARY, NOT ELSEWHERE CLASSIFIED NON-TUBERCULOUS DISEASES AND INJURIES OF THE RESPIRATORY SYSTEM 1. State if active malignant process is present. If so, nothing further is needed - 2. If malignancy is inactive, report date/place of last surgery, radiation or chemical therapy - 3. For non-malignant diseases, injuries, residuals of inactive or cured malignancies - a. Report structural changes to the lungs - b. Provide pulmonary function studies - c. Schedule additional special studies as necessary to evaluate any extra-pulmonary manifestations that may be detected - d. State whether the disease is in remission or demonstrably LOSS OF PENIS, ALL OR PARTIAL; IMPOTENCE (GU) A complete and detailed examination of the entire genitourinary system is needed with close correlation between this, the history and laboratory studies. Any penile deformity should be described in detail. 1. Extent of loss - 2. Erectile power preserved - 3. If impotent, state cause - 4. State whether impotence is permanent or if erectile power can be restored - 5. Describe any penile deformity in detail - Press RETURN No pending requests found for selected parameters. Pending 2507 Request Report Do you want to sort by: (A)ge of request (V)eteran name (R)outing location Selection: V// Answer must be A, S, V, or R. eteran name ge of request outing location Status selection: Select STATUS (enter A for all): P// Status must be N (new), P (pending), T (transcribed) or A (all) Age selection: Enter EARLIEST age: Enter the shortest time span (in days) which 2507 processing has elapsed. Cannot be less than one day ! If you want NEW requests (zero days), sort by status. and OLDEST age: Enter the longest time span (in days) which 2507 processing has elapsed. Cannot be less than 1 day Earliest age must be less than oldest age Routing Location Selection: Enter MEDICAL CENTER DIVISION: Do you want elapsed time reported in (C)alender days or (W)ork days? C// Must be C for Calendar, W for Workdays or simply press RETURN to accept the default. Calendar (Elapsed time in Work 2507 PENDING REPORT THE PERIPHERAL NERVES Narrative: None Examining provider: Examined on: Examination results: This exam was CANCELLED by the RO. MAS. Exam Results Continued Processing time: AGENT ORANGE Last rating exam date: Priority of exam: Site name not in file Continued on next page VA Form 2507 This exam has been reviewed and approved by the examining provider and signed by the veteran Approved by: ___________________________________ Date: _____________ Provider signature: ___________________________________ Date: _____________ You DIVISION NUMBER is incorrect. Your DIVISION NUMBER is invalid. C & P Exam Printing Note: All reports will be produced in 'terminal-digit' order. 2507 Final Exam Report Nothing to print Total requests to be printed: Final C&P Reports for print date Operator: Too many locations to store! Some locations may not be reported. A bad 'D' X-Reference exists on the 2507 Request File (#396.3) for Please notify IRM at the facility where you have created this report. POST-TRAUMATIC STRESS DISORDER A. Medical and occupational history: 1. Immediate pre-military events and details of training - 2. Events in the war zone - 3. Post-active service events (to present) - 4. Employment history prior to and following active service - B. Subjective complaints (include the veteran's history of unusually traumatic stressors) 1) Describe the duration of the disturbance from the symptoms shown above. Attachment A for Post-Traumatic Stress Disorder DSM-III-R Diagnostic Criteria for PTSD PITUITARY TUMORS - ACROMEGALY, PROLACTINOMA 1. Frequency of headaches - 2. Changes in vision - 3. Cardiac symptoms - 4. Joint pain - 6. Kyphosis of cervicodorsal spine - 7. Abnormal glucose tolerance - 8. Genital atrophy - lumps or masses diabetes mellitus thyroid disorders b. Head, eye, ear, nose and throat eye pain Ears: hearing loss external ear Nose: Mouth-throat: bleeding gums #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################