| 1 | English French Notes Complete/Exclude
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| 2 | MISCELLANEOUS NEUROLOGICAL DISORDERS
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| 3 | For MUSCULOSKELETAL, NOT ELSEWHERE CLASSIFIED
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| 4 | Type of Exam: MUSCULOSKELETAL, NOT ELSEWHERE CLASSIFIED
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| 5 | This 2507 already has appointments.
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| 6 | Enter '?' for help
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| 7 | Is this appointment due to a cancellation?
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| 8 | Enter NO if the appointment is not a reschedule of another appointment
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| 9 | made previously. Enter YES if the appointment is being scheduled because
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| 10 | an appointment has been or will be canceled.
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| 11 | '^' NOT ALLOWED
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| 12 | You have not selected the linked appointment being rescheduled. You may
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| 13 | need to adjust the link to the appointment with the AMIE link
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| 14 | management option to ensure proper processing time calculation for this 2507.
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| 15 | Enter Yes if the veteran requested a reschedule or 'No Showed' the appointment
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| 16 | Enter No if the Clinic required a reschedule.
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| 17 | Is this appointment due to a veteran requested cancellation or 'No Show'
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| 18 | You have not indicated if the reschedule was due to action by the veteran.
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| 19 | The new appointment will not be linked. You will need to adjust
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| 20 | the link for this appointment with the AMIE/C&P appointment link management
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| 21 | option to ensure proper processing time calculation for this 2507.
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| 22 | Remember to cancel the appointment for
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| 23 | and do NOT auto-rebook.
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| 24 | Hit Return to continue
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| 25 | Currently:
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| 26 | You have not selected a 2507 request to link the C&P appointment to.
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| 27 | The appointment should be linked with the AMIE/C&P Appointment Link
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| 28 | Management Option to ensure proper processing time calculation for this 2507
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| 29 | in the event of a veteran cancellation.
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| 30 | You have made a C&P appointment for a patient who has no pending 2507 request!
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| 31 | Adding new C&P appointment link for 2507 request dated
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| 32 | Adjusting C&P appointment link for 2507 request dated
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| 33 | MALIGNANCIES OR TUBERCULOSIS (GU)
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| 34 | 1. Disease active or inactive -
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| 35 | 2. If inactive, date last treatment or date determined inactive -
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| 36 | 3. Assess clinical findings -
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| 37 | 4. Assess laboratory findings -
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| 38 | Narrative: NONE
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| 39 | A. Medical history (note history of augmentation mammoplasty with
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| 40 | prosthetic implant or reduction mammoplasty):
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| 41 | 1. Axillary glands removal -
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| 42 | 2. Size of scar -
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| 43 | 3. Fixation of scar -
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| 44 | 4. Contour of scar -
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| 45 | 5. Muscle loss -
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| 46 | 6. Tenderness of scar -
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| 47 | 7. Nerve damage -
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| 48 | 8. Presence of aching, pain or limited use of upper extremeties -
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| 49 | 9. Note whether active malignant process is present -
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| 50 | 10. If malignancy is inactive, state date of last surgical, radiation
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| 51 | or chemical treatment -
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| 52 | MENTAL DISORDERS
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| 53 | A. Medical and occupational history
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| 54 | D. Specific evaluation information required by the rating board
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| 55 | E. Diagnostic tests (including psychological testing if deemed necessary):
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| 56 | For MENTAL, NOT ELSEWHERE CLASSIFIED
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| 57 | Type of Exam: MENTAL, NOT ELSEWHERE CLASSIFIED
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| 58 | MUSCLES (ORTHOPEDIC)
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| 59 | 1. Tissue loss comparison -
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| 60 | 2. Muscles penetrated -
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| 61 | 3. Scar formation measurement (sensitiveness, tenderness) -
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| 62 | 5. Damage to tendons -
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| 63 | 6. Damage to bones, joints, nerves -
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| 64 | 8. Evidence of pain -
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| 65 | 9. Evidence of muscle hernia -
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| 66 | MOUTH AND THROAT
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| 67 | All pertinent data must be recorded in the history in order
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| 68 | that the otolaryngological change discovered may be correlated
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| 69 | with evidence of disease found in other systems of the
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| 70 | 1. Oral cavity -
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| 71 | 5. Pyriform fossae -
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| 72 | Type of Exam: NEPHROLOGICAL
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| 73 | 1. Report presence or absence of calculi -
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| 74 | 2. If stone, presence and size if retained -
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| 75 | 3. Frequency of attacks of colic -
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| 76 | 4. Catheter drainage requirments, including frequency -
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| 77 | 5. Presence or absence of infection -
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| 78 | 6. Involvement of other kidney -
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| 79 | INTESTINE (DIGESTIVE)
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| 80 | in the
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| 81 | portion of this examination
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| 82 | is critical to the degree of disability assigned for the
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| 83 | 3. Is the veteran anemic? -
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| 84 | 6. Diarrhea and/or constipation -
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| 85 | 7. Bowel disturbance -
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| 86 | 8. Abdominal disturbance -
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| 87 | NECK, ABNORMALITIES OF,
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| 88 | NOT RESULT OF INJURY OR BONE DISEASE
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| 89 | The report of examination should include any abnormal position
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| 90 | of the head, range of motion of the head, evidence of
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| 91 | paralysis of the neck muscles, and asymmetry produced by
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| 92 | abnormal swelling or masses.
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| 93 | 1. Range of motion -
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| 94 | , NOT ELSEWHERE CLASSIFIED
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| 95 | 1) How does the residual disability affect the earning capacity
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| 96 | of the veteran in job performance?
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| 97 | 2) How does the residual disability affect normal everyday activities?
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| 98 | 3) If the disability has constant activity, are there
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| 99 | any periods of remission during the year?
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| 100 | 4) If there are acute exacerbations, what effects are there on
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| 101 | everyday life?
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| 102 | Compensation and Pension Exam for
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| 103 | For NEUROLOGICAL, NOT ELSEWHERE CLASSIFIED
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| 104 | Type of Exam: NEUROLOGICAL, NOT ELSEWHERE CLASSIFIED
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| 105 | NEPHRITIS, EXCEPT CHRONIC PYELONEPHRITIS
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| 106 | 2. Presence or absence of albumin casts -
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| 107 | 4. Red blood cells -
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| 108 | 5. Retention of non-protein nitrogen, creatinine or urea nitrogen -
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| 109 | 6. Describe overall impairment of kidney function -
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| 110 | 7. Report presence or absence of any cardiac complications -
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| 111 | Diagnosic/clinical test results:
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| 112 | NOSE AND SINUS
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| 113 | Report both functional and cosmetic impairment.
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| 114 | 1. External nose -
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| 115 | 2. Nasal vestibule -
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| 116 | 3. Right and left nasal cavities -
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| 117 | b. Floor of the nose -
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| 118 | c. Inferior meatus -
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| 119 | d. Inferior turbinates -
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| 120 | e. The middle meati -
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| 121 | f. The middle turbinate -
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| 122 | g. The spheno-ethmoidal recess -
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| 123 | h. The olfactory area -
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| 124 | i. The superior turbinates -
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| 125 | 4. The paranasal sinuses-
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| 126 | NOSE AND THROAT
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| 127 | Describe the location and nature of the injury or disease
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| 128 | with particular attention to the interference with speech,
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| 129 | sense of smell, and/or breathing space. If all or part of the
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| 130 | nose is missing provide
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| 131 | photographs. Localize manifestations
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| 132 | of chronic sinusitis, if present.
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| 133 | 1. Interference with breathing space -
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| 134 | 2. Headaches, severity, and frequency -
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| 135 | 3. Purulent discharge -
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| 136 | 4. Frequency of allergic attacks, baseline status in between -
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| 137 | 2507 Exams Not Scheduled Within Three Days
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| 138 | Enter STARTING DATE REPORTED TO MAS:
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| 139 | and ENDING DATE REPORTED TO MAS:
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| 140 | 2507 Requests Not Scheduled in Three Days at
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| 141 | A right margin of 132 is required for this output!
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| 142 | 2507 exams not scheduled in 3 days
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| 143 | SDATE*
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| 144 | HD*
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| 145 | Total requests:
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| 146 | patient file record missing
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| 147 | Date reported-MAS
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| 148 | Date scheduled
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| 149 | Requested by
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| 150 | For NEPHROLOGICAL, NOT ELSEWHERE CLASSIFIED
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| 151 | Type of Exam: NEPHROLOGICAL, NOT ELSEWHERE CLASSIFIED
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| 152 | For ORGANS OF SENSE, NOT ELSEWHERE CLASSIFIED
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| 153 | Type of Exam: ORGANS OF SENSE, NOT ELSEWHERE CLASSIFIED
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| 154 | Additional Veteran Information
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| 155 | Is this the correct Veteran
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| 156 | Enter Y if it is the correct Veteran, N to reselect
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| 157 | Edit Veteran Data
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| 158 | Want to edit it again
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| 159 | Enter Y to edit the information again or N to skip.
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| 160 | 1,5,0,2,0^...Error, required information missing!....
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| 161 | 0,7,0,1:2,0^...Unable to complete, Request aborted!.....
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| 162 | DVBA C NEW C&P VETERAN
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| 163 | PULMONARY TUBERCULOSIS AND MYCOBACTERIAL DISEASES
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| 164 | Is pulmonary tuberculosis or other mycobacterial disease
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| 165 | active? If so, identify the organism. In reactivated
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| 166 | cases, it is necessary to know whether this is reactivation
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| 167 | of the old disease or a separate and distinct new infection.
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| 168 | 1. IN ALL CASES:
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| 169 | a. Date of inactivity -
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| 170 | b. Extent of structural damage to lungs -
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| 171 | c. Provide pulmonary function studies -
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| 172 | 2. In PENSION CASES ONLY:
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| 173 | a. Disease condition after six months of treatment -
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| 174 | b. Disease condition after twelve months of treatment -
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| 175 | Additional note to the physician:
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| 176 | In all claims, if the disease is inactive and if the inactivity was confirmed
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| 177 | at a non-VA facility, obtain the name and mailing address of the facility
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| 178 | from the veteran so that the
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| 179 | Regional Office may request the report.
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| 180 | For PULMONARY, NOT ELSEWHERE CLASSIFIED
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| 181 | Type of Exam: PULMONARY, NOT ELSEWHERE CLASSIFIED
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| 182 | NON-TUBERCULOUS DISEASES AND INJURIES OF THE RESPIRATORY SYSTEM
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| 183 | 1. State if active malignant process is present. If so, nothing
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| 184 | further is needed -
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| 185 | 2. If malignancy is inactive, report date/place of last
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| 186 | surgery, radiation or chemical therapy -
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| 187 | 3. For non-malignant diseases, injuries, residuals of inactive or
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| 188 | cured malignancies -
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| 189 | a. Report structural changes to the lungs -
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| 190 | b. Provide pulmonary function studies -
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| 191 | c. Schedule additional special studies as necessary to evaluate
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| 192 | any extra-pulmonary manifestations that may be detected -
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| 193 | d. State whether the disease is in remission or demonstrably
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| 194 | LOSS OF PENIS, ALL OR PARTIAL; IMPOTENCE (GU)
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| 195 | A complete and detailed examination of the entire
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| 196 | genitourinary system is needed with close correlation
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| 197 | between this, the history and laboratory studies.
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| 198 | Any penile deformity should be described in detail.
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| 199 | 1. Extent of loss -
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| 200 | 2. Erectile power preserved -
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| 201 | 3. If impotent, state cause -
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| 202 | 4. State whether impotence is permanent or if erectile power
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| 203 | can be restored -
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| 204 | 5. Describe any penile deformity in detail -
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| 205 | Press RETURN
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| 206 | No pending requests found for selected parameters.
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| 207 | Pending 2507 Request Report
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| 208 | Do you want to sort by:
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| 209 | (A)ge of request
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| 210 | (V)eteran name
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| 211 | (R)outing location
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| 212 | Selection: V//
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| 213 | Answer must be A, S, V, or R.
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| 214 | eteran name
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| 215 | ge of request
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| 216 | outing location
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| 217 | Status selection:
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| 218 | Select STATUS (enter A for all): P//
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| 219 | Status must be N (new), P (pending), T (transcribed) or A (all)
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| 220 | Age selection:
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| 221 | Enter EARLIEST age:
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| 222 | Enter the shortest time span (in days) which 2507 processing has elapsed.
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| 223 | Cannot be less than one day !
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| 224 | If you want NEW requests (zero days), sort by status.
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| 225 | and OLDEST age:
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| 226 | Enter the longest time span (in days) which 2507 processing has elapsed.
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| 227 | Cannot be less than 1 day
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| 228 | Earliest age must be less than oldest age
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| 229 | Routing Location Selection:
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| 230 | Enter MEDICAL CENTER DIVISION:
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| 231 | Do you want elapsed time reported
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| 232 | in (C)alender days or (W)ork days? C//
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| 233 | Must be C for Calendar, W for Workdays
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| 234 | or simply press RETURN to accept the default.
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| 235 | Calendar
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| 236 | (Elapsed time in
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| 237 | Work
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| 238 | 2507 PENDING REPORT
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| 239 | THE PERIPHERAL NERVES
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| 240 | Narrative: None
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| 241 | Examining provider:
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| 242 | Examined on:
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| 243 | Examination results:
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| 244 | This exam was CANCELLED by
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| 245 | the RO.
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| 246 | MAS.
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| 247 | Exam Results Continued
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| 248 | Processing time:
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| 249 | AGENT ORANGE
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| 250 | Last rating exam date:
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| 251 | Priority of exam:
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| 252 | Site name not in file
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| 253 | Continued on next page
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| 254 | VA Form 2507
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| 255 | This exam has been reviewed and approved by the examining provider
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| 256 | and signed by the veteran
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| 257 | Approved by: ___________________________________ Date: _____________
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| 258 | Provider signature: ___________________________________ Date: _____________
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| 259 | You DIVISION NUMBER is incorrect.
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| 260 | Your DIVISION NUMBER is invalid.
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| 261 | C & P Exam Printing
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| 262 | Note: All reports will be produced in 'terminal-digit' order.
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| 263 | 2507 Final Exam Report
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| 264 | Nothing to print
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| 265 | Total requests to be printed:
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| 266 | Final C&P Reports for print date
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| 267 | Operator:
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| 268 | Too many locations to store! Some locations may not be reported.
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| 269 | A bad 'D' X-Reference exists on the 2507 Request File (#396.3) for
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| 270 | Please notify IRM at the facility where you have created
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| 271 | this report.
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| 272 | POST-TRAUMATIC STRESS DISORDER
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| 273 | A. Medical and occupational history:
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| 274 | 1. Immediate pre-military events and details of training -
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| 275 | 2. Events in the war zone -
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| 276 | 3. Post-active service events (to present) -
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| 277 | 4. Employment history prior to and following
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| 278 | active service -
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| 279 | B. Subjective complaints (include the veteran's history of unusually
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| 280 | traumatic stressors)
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| 281 | 1) Describe the duration of the disturbance from the symptoms shown above.
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| 282 | Attachment A for Post-Traumatic Stress Disorder
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| 283 | DSM-III-R Diagnostic Criteria for PTSD
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| 284 | PITUITARY TUMORS - ACROMEGALY, PROLACTINOMA
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| 285 | 1. Frequency of headaches -
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| 286 | 2. Changes in vision -
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| 287 | 3. Cardiac symptoms -
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| 288 | 4. Joint pain -
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| 289 | 6. Kyphosis of cervicodorsal spine -
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| 290 | 7. Abnormal glucose tolerance -
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| 291 | 8. Genital atrophy -
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| 292 | lumps or masses
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| 293 | diabetes mellitus
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| 294 | thyroid disorders
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| 295 | b. Head, eye, ear, nose and throat
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| 296 | eye pain
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| 297 | Ears:
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| 298 | hearing loss
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| 299 | external ear
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| 300 | Nose:
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| 301 | Mouth-throat:
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| 302 | bleeding gums
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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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