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 Enter Y to verify or N to reselect 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. However, you may cancel other individual exams. Press RETURN Do you want to cancel the entire exam Enter Y to cancel the ENTIRE exam or N to cancel ONLY selected exams Select EXAM TO CANCEL: for this Since all exams have been cancelled 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 Please enter cancellation code CANCELLED BY NO '^' ALLOWED AT THIS PROMPT This is a required response. CANCELLED BY Appointment was not linked to a 2507 request or was manually rebooked and linked to another appointment. (If the appointment was manually rebooked, you do not want to auto-rebook.) If the appointment was not properly linked, it will need to be linked with the AMIE/C&P appointment link management option. Hit Return to continue. This C&P appointment has multiple links with the same Current Appt Date. Use the AMIE/C&P Appointment Link Management option to review and delete any duplicate links. Hit any key to continue. 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. Select Exam: This exam is currently being edited. to continue. These exam results have been electronically signed. No editing is allowed! But you may make changes until it is released. This exam has been transferred to another facility. DVBA C 2507 EXAM READY Do you want to print a review copy 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 #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################