English	French	Notes	Complete/Exclude
that requires medical follow-up or a problem, which, if treated, may			
cause a change in hearing threshold levels -			
Summary of audiologic test results:			
Recommendations/remarks:			
Adequated by: ______________________________			
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2507 Exam Addition			
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 2. The leg.  The stump of an amputated leg will be measured from the insertion			
of the internal hamstring muscles to the bony end of the stump, with the			
subject recumbent and the leg flexed at 90 degrees.			
 3. The arm.  The stump of an amputated arm will be measured from the 			
anterior axillary fold to the bony end of the stump, with the stump hanging			
parallel to the chest wall.  Indicate whether the amputation site is above 			
or below the insertion of the deltoid muscle.  A statement of the			
remaining function is the best indicator of a disability's severity.			
 4. The forearm.  The stump of an amputated forearm will be measured from the			
insertion of the biceps tendon to the bony end, with the elbow flexed			
at 90 degrees.  Indicate if the amputation site is above or below the			
attachment of the pronator teres.			
 5. Parts below the wrist.  Amputations of fingers will be described as			
though the distal, middle, or proximal phalanx or as disarticulations through			
the distal interphalangeal, proximal interphalangeal, or metacarpophalangeal			
joint.  Resection of the head of the metacarpal will always be reported			
if shown.  Complete or partial loss or resection of bones of the hand will			
described in terms of the fraction of each remaining.  If surgery has			
altered the usefulness of remaining or transplanted digits, this will			
be described.			
 6. Parts below the ankle.  Complete or partial loss of toes or of			
metatarsal or tarsal bones will be described as in subparagraph five above.			
Always report loss of metatarsal head or other defects.  Indicate if			
amputation is through the tarsal-metatarsal joint and if any other portions			
of the bones of the foot remain.			
AMPUTATION STUMPS			
Amputations must be described in accordance with the following			
b. Amputation above insertion of deltoid muscle			
c. Amputation below insertion of deltoid muscle			
a. Above radial insertion of pronator teres (function is best indicator			
of disability)			
b. Below insertion of pronator teres			
a. Disarticulation, with loss of extrinsic pelvic girdle muscles			
b. Amputation of upper, middle or lower third, always measured			
from perineum to the boney end of the stump with the claimant			
recumbent and stump lying parallel with the other lower limb			
c. State whether this level permits satisfactory prosthesis			
a. Give level of amputation and condition of stump			
b. State whether this level permits satisfactory prosthesis			
c. Describe any stump defects (e.g. painful neuroma or circulatory			
A. Objective findings:			
7. Length of stump (see Attachment A) -			
8. Describe any limited motion or instability in			
the joint above the amputation site -			
Attachment A			
Length of stump			
 1. The thigh.  The stump of an amputated thigh will be measured from the			
perineum, at the origin of the adductor tendons, to the bony end of the stump,			
with the claimant recumbent and the stump lying parallel with the other			
lower limb.  It is to be kept in mind that if the limb is abducted,			
flexed, rotated or adducted, its length will be altered.  The effective length			
of a thigh stump is governed by its inside dimension.  Measure length of			
normal thigh if present and indicate whether amputation is in upper,			
middle, or lower third.  When amputation is bilateral, estimate the same			
for a person of similar height.			
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2507 Amis Report			
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 at end of month: 			
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Regional Office AMIS 290 Report for C&P Examinations			
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b. Describe the following:			
1.  General appearance and mental status -			
2.  Head and neck -			
H.  Indicate whether or not there is evidence of neoplasia in			
the veteran:			
I.  Indicate whether or not there is evidence of neoplasia in			
the veteran's family and specify the family member and type			
of neoplasia, if known:			
J.  Indicate if there is evidence of infertility, spontaneous			
abortions or teratogenesis in the veteran or the veteran's spouse			
or immediate family (and describe, if present):			
K.  Indicate if the veteran's spouse or children were in Vietnam			
(and if so, give details):			
L.  Diagnostic/clinical test results (indicate the results of			
the following, if performed):			
a.  Complete blood count, including differential -			
b.  Chest X-Ray (if no chest X-Ray within six months) -			
c.  Liver function profile -			
d.  Renal function profile -			
e.  Sperm count -			
f.  Referral to a dermatologist -			
N.  The veteran has been informed of the results of this examination,			
including X-Ray, blood chemistry, urinalysis, and CBC tests and the			
following abnormalities were discussed (if none, write			
Signature of veteran: 			
Examiner's signature: 			
Reviewed by: 			
Environmental Health Physician			
Full Exam Worksheet			
RESIDUALS OF DIOXIN EXPOSURE (AGENT ORANGE)			
Narrative:  			
A.  Initial data base for possible exposure to toxic chemicals:			
Branch of service: 			
Service serial number: 			
Dates of service:			
Last period: 			
Next to last period: 			
Date of birth: __________			
Marital status: ___ married ___ divorced ___ separated			
Did veteran have military service in Vietnam? ___ Yes  ___ No			
If yes, list all tours of duty in Vietnam:			
Indicate the Corps or area where veteran served in Vietnam:			
I Corps ___ II Corps ___ III Corps ___ IV Corps ___ Sea duty ___			
More than one ___ Don't know ___ Other (specify)			
List military units in which veteran served (specify complete			
unabbreviated titles such as company, battalion, etc.):			
B.  Veteran's exposure to Agent Orange (indicate one category for			
each circumstance):			
Definitely  Probably  Not    Definitely			
1. Veteran was involved in			
handling or spraying A.O.			
2. Veteran was not directly			
sprayed but was in a recently			
sprayed area.			
3. Veteran was exposed to			
herbicides other than A.O.			
4. Veteran was directly			
sprayed with Agent Orange.			
5. Veteran ate food or drink			
that could have been contaminated.			
C.  Indicate how many exposures the veteran alleges:			
D.  Indicate the nature of each exposure:			
E.  Medical history (include symptoms at time of exposure or			
later attributed by veteran to exposure):			
F.  Subjective complaints:			
G.  Objective findings:			
a. Height _____ weight _____ pulse _____ blood pressure _______			
REGULAR AID AND ATTENDANCE/HOUSEBOUND STATUS			
D. Present complaints (symptoms only, NOT diagnosis):			
E. Examination data:			
Height:			
Weight:			
Max wgt past year:			
Build and state of nutrition:			
Posture:			
Gait:			
General appearance:			
Pulse:			
Blood pressure:			
Respiration:			
L. Additional remarks as examiner deems necessary in individual case:			
Compensation and Pension Exam 			
daily services not required			
HIGHER LEVEL AID & ATTENDANCE			
BONES (FRACTURES/BONE DISEASE)			
Type of Exam:			
Evaluate the effect of functional impairment on gait, posture			
and specific functions of adjacent joints, muscles and nerves.			
b. False motion -			
3. Intra-articular involvement			
TRACHEA AND BRONCHI			
Identify the disease present, describe clinical findings			
and provide current chest X-Ray results if no recent			
studies are available.  Report pulmonary function studies			
unless medically contraindicated.			
1. Presence of cor pulmonale -			
2. If veteran is asthmatic, report frequency of attacks			
and baseline functional status between attacks -			
3. Report any indications of cyanosis/clubbing of extremities -			
4. Productive cough/sputum -			
5. Dyspnea on exertion/slight exertion/at rest -			
6. Indicate whether infectious disease is present -			
Diagnostic/clincal test results:			
==========================<  Additional comments  >==========================			
The following veteran had one or more 2507 exams added:			
     Request date: 			
Note:  Scheduling for this request must now be recompleted.			
       A new request copy will be printed tomorrow morning.			
DVBA C EXAM ADDED			
Bulletin not sent.			
DVBA C EXAM ADDED mail group not found.			
Addition of 2507 Exams			
Cancellation comments:			
A bulletin will now be sent to the 2507 Cancellation mail group.			
Exams cancelled                               Reason			
 *** All exams on this request are now CANCELLED. ***			
 open on this request. ***			
 *** This request is now COMPLETE and should be released by MAS ***			
DVBA C 2507 CANCELLATION			
2507 mail group NOT found!  Bulletin not sent.			
Cancellation of 2507 Exams			
Undetermined			
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