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