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			
####################	####################	####################	
####################	####################	####################	
####################	####################	####################	
####################	####################	####################	
####################	####################	####################	
