English	French	Notes	Complete/Exclude
For CARDIOVASCULAR, NOT ELSEWHERE CLASSIFIED			
Type of Exam: CARDIOVASCULAR, NOT ELSEWHERE CLASSIFIED			
Physician's Guide Reference:  None			
Request date			
Regional office number			
Requester			
Priority of exam			
Request status			
** No exams selected **			
This report will check the 2507 REQUEST file for missing crucial data.			
All requests will be checked and those found missing any of the following			
will be reported:			
1)  Request date			
2)  Regional office number			
4)  Priority of exam			
5)  Request status			
6)  Routing location			
7)  No exams selected			
8)  Requests older than 3 days without C&P Appt links 			
Enter Y to print the report or N to quit.			
2507 exam integrity report			
C & P Exam Integrity Report			
Nothing found to report			
Social Sec #			
Missing items			
Enter REASON FOR CANCELLATION: 			
Cancelled by (M)AS or (R)O?  M//  			
Enter M to indicate cancellation by MAS or			
 R to indicate cancellation by the Regional Office.			
Cancelled by 			
Unknown source			
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None - (Request only)			
Unknown exam			
Cancellation error on 			
Entire exam is now CANCELLED.			
Cancellation error !			
An error has occurred during cancellation - bulletin will not be sent!			
I am sending a copy of this cancellation to the			
cancellation mail group at 			
since this was transferred in.			
2507 Exam Veteran Selection			
2507 Test Cancellation			
Select VETERAN: 			
Zeroth node for ^DPT record missing!			
This request cannot be cancelled entirely because			
 one or more exams have 			
been transferred.			
been completed.			
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 for this 			
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the entire request will be CANCELLED.			
 for this request:			
This exam or request has been 			
cancelled by the RO			
cancelled by MAS			
completed, transferred out			
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CANCELLED BY			
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CANCELLED BY 			
Appointment 			
 was not linked to a 2507 request or was			
 manually rebooked and linked to another appointment.			
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 AMIE/C&P appointment link management option.			
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Use the AMIE/C&P Appointment Link Management option to review and delete			
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AMIE C&P Appt Link update			
Initial Appt Date: 			
Current Appt Date: 			
has been cancelled!			
has been cancelled and rebooked for 			
THE CRANIAL NERVES			
1.  Identify the nerve and the side -			
2.  Identify the disorder (paralysis, neuritis, neuralgia) -			
3.  Describe in detail, quantifying as much as possible, the			
motor and sensory impairment.  Note if the entire nerve is			
affected or only that part of the distribution distal to a			
particular localized lesion -			
4.  Is tinnitus present?  If so is it constant or intermittent? -			
HYPERPITUITARISM (CUSHING'S SYNDROME)			
1.  Muscular weakness -			
2.  Decalcification of bones -			
4.  Enlarged sella turcica, pituitary or adrenal glands -			
5.  Nervous, cardiovascular or gastrointestinal -			
6.  Disease in remission or demonstrably active -			
7.  Continuous medication required -			
CYSTITIS, BLADDER CALCULUS, RESIDUALS OF BLADDER INJURY,			
ALL DISORDERS OF THE PROSTATE, URETHRA AND SURGICAL RESIDUALS (GU)			
Complications and/or medical side effects should always be			
reported, even when not specifically requested.			
1. Frequency of urination -			
2. Presence or absence of pyuria -			
3. Pain or tenesmus -			
4. Incontinence requiring pads or appliance -			
DISEASES OF THE ARTERIES AND VEINS (CARDIOVASCULAR)			
Once a diagnosis is established, details about the			
permanent medical residuals and how they affect the			
veteran's industrial capabilities are very important as			
the degree of impairment is used by the rating board to			
determine the percentage of disability and payments therefore.			
A. Medical history  (if a disability is already service connected, then			
provide data since last VA rating examination):			
1. Blood pressure -			
3. Skin appearance -			
4. Skin temperature (to the touch) -			
6. Cardiac involvement -			
DISEASES/INJURIES OF THE BRAIN			
1.  State if a tumor is present.  If so, note type and whether 			
2.  If a malignancy is present but is now cured or in remission,			
report the date of last surgery, radiation therapy, chemotherapy			
or other treatment -			
3.  Describe in detail the motor and sensory impairment of the affected			
cranial nerves -			
4.  Describe in detail any functional impairment of the peripheral			
and autonomic systems -			
5.  Describe any psychiatric manifestations in detail -			
For DIGESTIVE, NOT ELSEWHERE CLASSIFIED			
Type of Exam: DIGESTIVE, NOT ELSEWHERE CLASSIFIED			
DISEASES OF THE HEART (CARDIOVASCULAR)			
In developing the diagnosis of a cardiac condition, the			
NOMENCLATURE AND CRITERIA FOR DIAGNOSIS OF DISEASE			
OF THE HEART published by the New York Heart Association			
serves as an acceptable standard.  If a stress test			
could be conducted without cardiovascular contraindications			
but physical problems preclude, please state.			
3. X-Ray results -			
4. Stress test (after EKG, if indicated) -			
DIABETES INSIPIDUS			
1.  Frequency of urination -			
2.  Frequency of excessive thirst -			
3.  Frequency of syncope -			
4.  Blood pressure readings -			
5.  Serum osmolality (m Osm/Kg) -			
6.  Urine osmolality (m Osm/Kg) -			
DIABETES MELLITUS			
1.  Frequency of ketoacidosis or hypoglycemic reactions -			
2.  Restricted diet and/or regulation of activities -			
3.  Loss of weight and strength since last exam -			
4.  Anal pruritis -			
5.  Vascular deficiencies -			
6.  Diabetic ocular disturbances -			
7.  Daily insulin requirements (type and amount) -			
8.  Blood sugar -			
9.  Blood pressure -			
1.  Disability effect on everyday activities -			
2.  Ancillary problems as a result of the dental condition -			
AUDIO-EAR DISEASE			
If, in the course of audiometric testing, there is any			
indication of ear disease, the veteran should be referred to			
a physician for additional exam.  Examination should include			
inspection of the auricle, the external canal, and tympanic			
membranes.  Abnormalities in size, shape, or form of the			
structure should be noted.			
2. External canal -			
3. Tympanic membrane -			
4. The tympanum -			
5. The mastoid -			
5. State if an active ear disease is present -			
6. State if an infectious disease of the middle or inner			
ear is present -			
7. State whether ear disease is affecting any function other			
than hearing, such as balance, or is associated with any			
upper respiratory disease -			
2507 Exam Data Entry			
This request has not been reported to MAS and may not be transcribed.			
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This exam has been transferred to another facility.			
DVBA C 2507 EXAM READY			
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Enter Y to print a copy of the results for review			
or N to continue editing.			
2507 Review Report			
DVBC*			
2507 Request queued for review to device 			
1.  State the frequency and type of seizures during the past			
twelve months, including any change in frequency pattern.  If			
possible, get the actual number of seizures in each calendar			
month.  If the veteran keeps a seizure diary, get dates of			
2.  If a medical examiner observes any indications of psychiatric			
disease associated with epilepsy, a psychiatric consultation			
should be ordered.			
2507 Request Inquiry			
    Date of request: 			
Enter VETERAN NAME: 			
C&P Request Inquiry			
COMPENSATION AND PENSION EXAM INQUIRY			
Res Phone: 			
Bus Phone: 			
Exam(s) transferred to another site -- see pending report.			
Other Disabilities:			
Rated Disability			
ESOPHAGUS (DIGESTIVE)			
This area of examination is limited to conditions			
from mouth to the esophagogastric sphincter.			
A. Medical history :			
1. Current weight -			
2. Maximum weight, past year -			
4. Disturbance of motility -			
5. Actual partial obstruction (indicate frequency of dilatation			
if required) -			
6. Reflux disturbances -			
7. Presence of pain -			
Print Exam Checklist for the Regional Office			
A margin of 132 is required for this printout			
Print Exam check list			
VA Regional Office - 			
Compensation and Pension Examination Request Worksheet			
Veteran's Name: _________________________________________________			
VAMC: __________________________			
SSN: __________________________			
Telephone-Day: _______________________  Night:_______________________    Power of Attorney: _________________			
Date Ordered: ____________________________			
By: __________________________			
Priority of Exam:  _________________________         (    ) Insufficient Exam Dated: _______________________			
(    ) General Medical Examination                   (    ) Review of Pertinent Medical Records in			
Print Cover Sheet for Fee Exam			
Number of copies: 			
You cannot print less than one or more than ten copies per session.			
Fee exam cover sheets should be sent to a printer.			
Print C&P Fee Cover Sheet			
URETHRAL OR BLADDER FISTULA (GU)			
1. Number and location of fistulae -			
2. Drainage constant or intermittent -			
3. Constant use of pad or appliance -			
4. Frequency of pad changing -			
FEET (ORTHOPEDIC)			
The findings in each foot will be separately and carefully			
described, as this will affect the evaluation.  The nomenclature			
of toes for examination purposes will be the great toe, the second,			
third, fourth and fifth toes, named from the medial or inner side			
and which foot is being examined.  The functional loss should			
be related to the anatomical condition.			
1. Posture (standing, squatting, supination, pronation and			
rising on toes and heels) -			
6. Secondary skin and vascular changes -			
For GENITOURINARY, NOT ELSEWHERE CLASSIFIED			
Type of Exam: GENITOURINARY, NOT ELSEWHERE CLASSIFIED			
GENERAL MEDICAL			
A. Occupational history (List most current first):			
Name/Address of employer     Type      Monthly     Emp dates      Time lost			
(if unemployed, enter none)			
Work      Wages       from/to        Last 12 mo			
State if time from employment was lost and give reasons.			
B. Medical history (since last rating exam):			
C. Present complaints (symptoms only, NOT diagnosis):			
D. Examination data:			
Temperature:			
Time:			
AM/PM			
Carriage:			
Right- or left-handed:			
(How determined)			
E. Skin, including appendages 			
F. Lymphatic and hemic systems 			
G. Head, face and neck:			
H. Nose, sinuses, mouth and throat (include gross dental findings):			
I. Ears (describe canals, drums, perforations, discharge):			
J. Eyes (describe external eye, pupil reaction, movements,			
field of vision, any uncorrectable refractive error or			
any retinopathy):			
K. Cardiovascular system 			
(describe thrust, size, rhythm, sounds and condition			
   of peripheral vessels):			
Pulse			
Blood pressure			
Respiration			
Sitting			
Recumbent			
Standing			
Sitting after exerc. 			
2 min after exercise 			
L. Varicose veins (describe location, size, extent, ulcers, scars, and			
   competency of deep circulation):			
M. Respiratory system 			
N. Digestive system 			
P. Genito-urinary system 			
Q. Musculo-skeletal system			
R. Endocrine system (describe disease of thyroid, pituitary, adrenals			
gonads, other body systems affected, etc.):			
S. Nervous system			
U. Other tests/exams recommended:			
V. Diagnostic/clinical test results:			
Reviewing Official: ______________________________			
An evaluation of the female reproductive system depends			
on a complete physical examination, a thorough medical			
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