308 lines
12 KiB
Plaintext
308 lines
12 KiB
Plaintext
English French Notes Complete/Exclude
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that requires medical follow-up or a problem, which, if treated, may
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cause a change in hearing threshold levels -
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Summary of audiologic test results:
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Recommendations/remarks:
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Adequated by: ______________________________
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No exams selected ...
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Worksheets should be sent to a printer.
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Print C&P Work Sheets
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DA*
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TEMP*
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Print/Reprint C&P Worksheets
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Select VETERAN NAME:
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Select exam(s) to print or enter ALL to print all exams.
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Select EXAM:
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Status is not OPEN - No worksheet will be printed.
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Please select the exams for
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Use ? to see a list exams available for selection.
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-- already ON FILE
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-- Previously cancelled, addition allowable
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You have not selected any exams.
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Do you want to try again
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Enter Y to select more exams or N to abort adding exams to this request.
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You have selected:
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Is this exam
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Are these exams
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Enter EXAM to delete:
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Want to add more exams
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Enter Y to add more exams or N to go on and log existing selections.
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Another user adding exams now...try again later.
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PRESS [Return] TO CONTINUE...
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Do you want to print worksheets
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Enter Y to print worksheets for items just entered or
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N to skip.
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Add a C & P Exam for
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Veteran Selection
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Exam selection
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2507 Exam Addition
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This request is a TRANSFER IN and exams cannot be added.
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This request has been
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transferred in
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given an incorrect status
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Press RETURN
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Veteran name:
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Edit Address Information
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Permanent
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Temporary:
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City:
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State:
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Zip+4:
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County:
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Phone:
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Office:
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Do you wish to edit this address:
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AMIE Package
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Edit of patient address
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DVBA C EDIT ADDRESS
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DVBCML(
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A bulletin has been sent to the appropriate mail group regarding this
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address change!
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ADDR.:
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City:
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State:
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Zip+4:
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2. The leg. The stump of an amputated leg will be measured from the insertion
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of the internal hamstring muscles to the bony end of the stump, with the
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subject recumbent and the leg flexed at 90 degrees.
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3. The arm. The stump of an amputated arm will be measured from the
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anterior axillary fold to the bony end of the stump, with the stump hanging
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parallel to the chest wall. Indicate whether the amputation site is above
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or below the insertion of the deltoid muscle. A statement of the
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remaining function is the best indicator of a disability's severity.
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4. The forearm. The stump of an amputated forearm will be measured from the
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insertion of the biceps tendon to the bony end, with the elbow flexed
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at 90 degrees. Indicate if the amputation site is above or below the
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attachment of the pronator teres.
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5. Parts below the wrist. Amputations of fingers will be described as
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though the distal, middle, or proximal phalanx or as disarticulations through
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the distal interphalangeal, proximal interphalangeal, or metacarpophalangeal
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joint. Resection of the head of the metacarpal will always be reported
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if shown. Complete or partial loss or resection of bones of the hand will
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described in terms of the fraction of each remaining. If surgery has
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altered the usefulness of remaining or transplanted digits, this will
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be described.
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6. Parts below the ankle. Complete or partial loss of toes or of
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metatarsal or tarsal bones will be described as in subparagraph five above.
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Always report loss of metatarsal head or other defects. Indicate if
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amputation is through the tarsal-metatarsal joint and if any other portions
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of the bones of the foot remain.
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AMPUTATION STUMPS
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Amputations must be described in accordance with the following
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b. Amputation above insertion of deltoid muscle
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c. Amputation below insertion of deltoid muscle
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a. Above radial insertion of pronator teres (function is best indicator
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of disability)
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b. Below insertion of pronator teres
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a. Disarticulation, with loss of extrinsic pelvic girdle muscles
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b. Amputation of upper, middle or lower third, always measured
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from perineum to the boney end of the stump with the claimant
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recumbent and stump lying parallel with the other lower limb
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c. State whether this level permits satisfactory prosthesis
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a. Give level of amputation and condition of stump
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b. State whether this level permits satisfactory prosthesis
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c. Describe any stump defects (e.g. painful neuroma or circulatory
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A. Objective findings:
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7. Length of stump (see Attachment A) -
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8. Describe any limited motion or instability in
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the joint above the amputation site -
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Attachment A
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Length of stump
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1. The thigh. The stump of an amputated thigh will be measured from the
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perineum, at the origin of the adductor tendons, to the bony end of the stump,
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with the claimant recumbent and the stump lying parallel with the other
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lower limb. It is to be kept in mind that if the limb is abducted,
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flexed, rotated or adducted, its length will be altered. The effective length
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of a thigh stump is governed by its inside dimension. Measure length of
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normal thigh if present and indicate whether amputation is in upper,
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middle, or lower third. When amputation is bilateral, estimate the same
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for a person of similar height.
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Processing date:
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Total pending from previous month:
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Requests received for date range:
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Exams returned as insufficient:
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Requests returned complete:
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Requests returned incomplete:
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Total processing time:
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Pending end of month:
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Average processing time:
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Greater than 3 days to schedule:
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Greater than 30 days to examine:
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Pending, 0-90 days:
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Pending, 91-120 days:
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Pending, 121-150 days:
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Pending, 151-180 days:
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Pending, 181-365 days:
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Pending, 366 or more days:
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Transfers in from other sites:
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Transfers returned to other sites:
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Transfers pending return to other sites:
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Transfers out to other sites:
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Transfers returned from other sites:
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Transfers pending return from other sites:
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** Transfer figures are for information only **
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* and should not be used to balance this report *
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Bulletin will NOT be sent!!
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AMIS 290 report for
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Loading AMIS 290 bulletin ...
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>> Mail message transmitted <<
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AMIS 290 Report for
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For date range:
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AMIS 290 REPORT
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Enter STARTING DATE:
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and ENDING DATE:
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Invalid date sequence - ending date is before starting date.
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Please enter the total pending from the previous month:
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Enter the totals for the month previous to the one you are processing.
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Must be a number from 0 to 9999.
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Do you want to send a bulletin when processing is done
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Enter Y to send a bulletin to selected recipients or N not to send it at all.
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2507 Amis Report
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RO*
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TOT*
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DVBCDT(0)
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XM*
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For regional office:
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Requests sent for date range:
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Exams received incomplete:
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Exams received complete:
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Pending for office
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at end of month:
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Greater than 5 days to schedule:
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Greater than 45 days to examine:
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Press RETURN to continue
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Regional Office AMIS 290 Report for C&P Examinations
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Page: 1
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When selecting regional offices you may enter individual
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station name or station number.
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Select REGIONAL OFFICE NUMBER:
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Want to send a bulletin when processing is done
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Enter Y to send the bulletin to selected recipients or N not to send it at all.
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b. Describe the following:
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1. General appearance and mental status -
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2. Head and neck -
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H. Indicate whether or not there is evidence of neoplasia in
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the veteran:
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I. Indicate whether or not there is evidence of neoplasia in
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the veteran's family and specify the family member and type
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of neoplasia, if known:
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J. Indicate if there is evidence of infertility, spontaneous
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abortions or teratogenesis in the veteran or the veteran's spouse
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or immediate family (and describe, if present):
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K. Indicate if the veteran's spouse or children were in Vietnam
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(and if so, give details):
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L. Diagnostic/clinical test results (indicate the results of
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the following, if performed):
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a. Complete blood count, including differential -
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b. Chest X-Ray (if no chest X-Ray within six months) -
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c. Liver function profile -
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d. Renal function profile -
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e. Sperm count -
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f. Referral to a dermatologist -
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N. The veteran has been informed of the results of this examination,
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including X-Ray, blood chemistry, urinalysis, and CBC tests and the
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following abnormalities were discussed (if none, write
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Signature of veteran:
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Examiner's signature:
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Reviewed by:
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Environmental Health Physician
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Full Exam Worksheet
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RESIDUALS OF DIOXIN EXPOSURE (AGENT ORANGE)
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Narrative:
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A. Initial data base for possible exposure to toxic chemicals:
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Branch of service:
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Service serial number:
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Dates of service:
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Last period:
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Next to last period:
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Date of birth: __________
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Marital status: ___ married ___ divorced ___ separated
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Did veteran have military service in Vietnam? ___ Yes ___ No
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If yes, list all tours of duty in Vietnam:
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Indicate the Corps or area where veteran served in Vietnam:
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I Corps ___ II Corps ___ III Corps ___ IV Corps ___ Sea duty ___
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More than one ___ Don't know ___ Other (specify)
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List military units in which veteran served (specify complete
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unabbreviated titles such as company, battalion, etc.):
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B. Veteran's exposure to Agent Orange (indicate one category for
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each circumstance):
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Definitely Probably Not Definitely
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1. Veteran was involved in
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handling or spraying A.O.
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2. Veteran was not directly
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sprayed but was in a recently
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sprayed area.
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3. Veteran was exposed to
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herbicides other than A.O.
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4. Veteran was directly
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sprayed with Agent Orange.
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5. Veteran ate food or drink
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that could have been contaminated.
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C. Indicate how many exposures the veteran alleges:
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D. Indicate the nature of each exposure:
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E. Medical history (include symptoms at time of exposure or
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later attributed by veteran to exposure):
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F. Subjective complaints:
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G. Objective findings:
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a. Height _____ weight _____ pulse _____ blood pressure _______
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REGULAR AID AND ATTENDANCE/HOUSEBOUND STATUS
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D. Present complaints (symptoms only, NOT diagnosis):
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E. Examination data:
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Height:
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Weight:
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Max wgt past year:
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Build and state of nutrition:
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Posture:
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Gait:
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General appearance:
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Pulse:
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Blood pressure:
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Respiration:
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L. Additional remarks as examiner deems necessary in individual case:
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Compensation and Pension Exam
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daily services not required
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HIGHER LEVEL AID & ATTENDANCE
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BONES (FRACTURES/BONE DISEASE)
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Type of Exam:
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Evaluate the effect of functional impairment on gait, posture
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and specific functions of adjacent joints, muscles and nerves.
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b. False motion -
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3. Intra-articular involvement
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TRACHEA AND BRONCHI
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Identify the disease present, describe clinical findings
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and provide current chest X-Ray results if no recent
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studies are available. Report pulmonary function studies
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unless medically contraindicated.
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1. Presence of cor pulmonale -
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2. If veteran is asthmatic, report frequency of attacks
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and baseline functional status between attacks -
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3. Report any indications of cyanosis/clubbing of extremities -
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4. Productive cough/sputum -
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5. Dyspnea on exertion/slight exertion/at rest -
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6. Indicate whether infectious disease is present -
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Diagnostic/clincal test results:
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==========================< Additional comments >==========================
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The following veteran had one or more 2507 exams added:
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Request date:
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Note: Scheduling for this request must now be recompleted.
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A new request copy will be printed tomorrow morning.
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DVBA C EXAM ADDED
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Bulletin not sent.
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DVBA C EXAM ADDED mail group not found.
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Addition of 2507 Exams
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Cancellation comments:
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A bulletin will now be sent to the 2507 Cancellation mail group.
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Exams cancelled Reason
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*** All exams on this request are now CANCELLED. ***
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open on this request. ***
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*** This request is now COMPLETE and should be released by MAS ***
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DVBA C 2507 CANCELLATION
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2507 mail group NOT found! Bulletin not sent.
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Cancellation of 2507 Exams
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Undetermined
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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