**PLEASE SEE THE LAST PAGE FOR HELPFUL HINTS FROM THE SEVEN STEPS
TEAM:**

PERFORMANCE WORK STATEMENT (PWS)

**A.1 INTRODUCTION**

A.1.1 The title of this PWS is the Contract Medical Disability
Examination Project. Public Law 104-275 authorized the Department of
Veterans Affairs (VA) to conduct a limited pilot program to contract for
medical examinations from non-VA medical sources at up to 10 VA regional
offices (VARO). The pilot commenced on May 1, 1998 and will terminate
with the current contractor on April 30, 2003. An expiration date for
this authority was not specified; therefore, the VA is planning to
select a contractor for another five-year period to begin on May 1,
2003, through April 30, 2008. Performance will constantly be measured.
The goal of this and other concurrent VA initiatives is to
quantitatively improve the overall level of service provided the
nation\'s veteran population. The volume of disability examinations is
approximately 50,000 to 60,000 per year for the 10 regional offices and
22 Benefits Delivery at Discharge (BDD) sites.

A.1.2 Participating VAROs currently include: Greater Atlanta, including
North and Central Georgia (including BDD sites Ft. Benning, Ft. Gordon,
Ft. Stewart); Boston; Houston and San Antonio, Texas (including Brooks
AFB, Corpus Christi, Ft. Sam Houston, Lackland AFB, Randolph AFB, and
Sheppard AFB); Greater Los Angeles; Muskogee (to include Altus AFB, Ft.
Sill, Sheppard AFB, Tinker AFB and Vance AFB); Roanoke (to include
Portsmouth); Salt Lake City (to include Hill AFB); San Diego (Riverside
county and Camp Pendleton); Seattle and surrounding areas (including
Bremerton Naval Station), and the Spokane area; and Winston-Salem
(Coastal and Mountain areas of North Carolina and Camp Lejeune, Ft.
Bragg, Pope AFB, and Seymour-Johnson AFB). A specific portion of the
examinations within the jurisdiction of these VAROs will be dedicated to
the contractor. These locations are subject to change as required by the
VA in which 60-90 days ramp-up time will be provided to the contractor
to hire and train additional personnel.

**B.1 BACKGROUND**

B.1.1 The VA annually administers, through the Veterans Benefits
Administration (VBA), a compensation and pension (C&P) program valued at
approximately \$22 billion in annual benefit payments. Benefits are paid
to veterans, their dependents, and their survivors. Entitlement
determinations for disability compensation (based on disabilities deemed
to be service related) and disability pension (needs based entitlement
for wartime veterans with non-service related disabilities) are made by
disability panels located at 57 VAROs. Generally, jurisdiction for
compensation and original pension payments corresponds with state
boundaries, but with jurisdiction divided between three VAROs for
California and two VAROs each for New York, Pennsylvania, and Texas. A
VARO located in San Juan has jurisdiction for veterans residing in
Puerto Rico and the Virgin Islands. A VARO located in Manila has
jurisdiction over Philippine cases.

B.1.2 Annually, the VA receives over 120,000 original disability
compensation claims, over 390,000 reopened compensation claims, and over
30,000 pension claims. Examinations for disability determination
purposes are conducted at local VA medical centers (VAMC) based upon
VARO requests. More than 300,000 are performed annually. Examinations
are required to support original disability determinations, claims for
increased benefits, appellate reviews, and for review of disabilities
considered likely to improve.

**C.1 SCOPE\
**

C.1.1 Contractor shall have the capability to receive an encrypted text
file (format predetermined by the VA), and process a quantity of 200-400
VA examination requests on a daily basis. Daily workload will fluctuate
depending on the current VA workload trends. The current daily average
is 237.

C.1.2 Contractor shall schedule examinations. The contractor shall
notify the veteran at least five days prior to the scheduled
appointment.

C.1.2.1 Contractor shall provide the VARO a copy of the examination
notification letter and forward a copy to any documented Power of
Attorney (POA)/Veteran Service Organization representative.

C.1.3 Contractor shall schedule examinations as close to the veteran\'s
home of record as feasible; but no further than (30) miles for
non-specialist examination and one hundred (100) miles for specialist
examinations. The VA will give consideration to allowing for greater
distances for remote geographical areas where examiners and specialists
may be scarce due to smaller populations; however, every effort shall be
made by the contractor to find a physician as close to the veteran\'s
home as possible.

C.1.4 Contractor shall provide physicians a copy of the veteran\'s
medical records prior to the examination in a secure manner. The VA
claims file may not be sent to the examiner. A claims file will not be
sent to the contractor for every examination request.

C.1.4.1 Contractor shall be responsible for returning the veterans
claims folders assembled in the same order in which they were received
no later than five workdays after completion of the requested
examination. The contractor shall ensure that the records are returned
via a secure, traceable, mailing method.

C.1.5 Contractor shall provide state licensed, board certified
physicians to conduct examinations and appropriate facilities to conduct
required laboratory testing, for the following areas such as:
musculoskeletal; organs of sense, infectious, immune, and nutritional
deficiencies; respiratory; cardiovascular; digestive; genitourinary;
gynecological and breast; hemic and lymphatic; skin; endocrine;
neurologic; mental disorders; dental and oral examinations. Time begins
on the date the contractor receives the examination request and ends on
the date the report is delivered to the VA.

Examinations for the following categories will remain within the VA
system except for special exception cases that will be agreed upon in
advance by VA and the contractor: Original Gulf War Environmental Claims
for undiagnosed illnesses; U.S. Court of Veterans Appeals cases;
examinations for Aid and Attendance/Housebound benefits; examinations
requiring hospitalization or surgical evaluation, such as sleep apnea or
endometriosis needing laparoscopy; former Prisoners of War; 38 USC 1151
initial determinations; veterans residing in VA domiciliaries/nursing
homes; and incarcerated veterans. In addition, no requests for review of
records in the determination of Death Indemnity Compensation (DIC) will
be sent to the contractor.

C.1.5.1 Contractor shall ensure that examinations for audiology are
conducted by State licensed audiologists who will use the Maryland CNC
hearing test.

C.1.6 Contractor shall ensure that physicians are compliant with OSHA
and the American Disabilities Act.

C.1.7 Contractor shall conduct examinations in accordance with Exhibit
2. Contractor shall examine all conditions listed in the examination
request and address all factors in the examination worksheets. Changes
made to the examination worksheets by VA will be provided to the
contractor within seven calendar days and will not revise the price
schedule.

C.1.8 Contractor shall monitor physicians\' offices to ensure that
veterans are seen within one hour of the scheduled appointment time.
Contractor shall investigate tardiness and habitual delays with
physicians and take corrective action to eliminate or minimize future
delays.

C.1.9 Contractor shall document in the examination report that all
gyynecological, rectal/anal and breast examinations are performed by a
physician in the presence of a female assistant for female patients.

C.1.10 Contractor shall conduct only those tests specifically required
in the worksheets. Contractor shall not conduct invasive testing without
prior approval from the VARO requesting the examination.

C.1.11 Contractor shall forward to VA completed examination reports
within 38 days of receipt.

C.1.12 Contractor\'s examination reports shall be no more than 4-6%
insufficient which will be measured quarterly by random sample.

C.1.13 Contractor shall return insufficient examination reports to VA
within 14 calendar days without additional charge. Insufficient
examination reports are those that do not meet the examination
worksheets requirements (i.e., no diagnosis, no testing performed, etc.)
The only exception will be for charges incurred due to additional tests
authorized by VA.

C.1.14 Contractor shall pay veterans a travel reimbursement of eleven
(11) cents a mile, unless the examination is conducted in the same city
in which the individual examined resides. The contractor shall pay
travel expense reimbursements directly to the individuals at the time
they report for the examination. Contractor shall reimburse veterans for
tolls (bridges, etc.). Contractor shall reimburse severely disabled
veterans for taxi fares when there is no other means of transportation
to the examination site.

C.1.15 Contractor shall have the capability to send and receive e-mail
and provide those addresses to the VAROs.

C.1.16 The contractor shall provide VA access to its Management
Information System for real-time status information such as veteran
examination requests.

C.1.17 Contractor shall provide toll-free access for veterans to call
with questions regarding their scheduled appointments. The contractor
shall provide access to their administrative office from 8 AM to 7 PM
Eastern time.

C.1.18 Contractor shall resolve any erroneous bills received by
veterans.

C.1.19 Contractor shall appoint a program manager to be responsible for
effective liaison with VARO examination coordinators and the VA Central
Office (VACO) program manager.

C.1.20 Contractor shall maintain a database (.dbf format compatible) of
examination requests and provide a monthly status report to each VARO
and VACO.

C.1.21 Contractor shall provide the VA with an electronic version of
their monthly invoices to the VA project manager for payment processing
containing the following information: a list of services performed (an
invoice), including examination category(s), tests completed with
related Current Procedural Terminology (CPT) codes, descriptive titles
and associated fees.

C.1.22 Contractor shall develop with the VA COTR, and bear the cost of,
a customer survey card/questionnaire with no more than five questions
and an instruction letter to be issued to every veteran at the time
he/she checks in with the receptionist at the physician\'s office (prior
to examination). Contractor shall bear the cost of postage and provide
the independent contractor\'s return address so that the independent
contractor can tally the results on an ongoing basis. Development of the
customer survey card shall take place after contract award and the first
five months of the contract period shall be considered a test period
where no incentives/deductions are applicable.

**D.1 APPLICABLE DIRECTIVES**

C&P examination worksheets are attached in Exhibit 2.

**E.1 PERFORMANCE REQUIREMENTS**

See Performance Requirement Summary, Exhibit No. 1.

**F.1 DELIVERABLES**

F.1.1 [Performance Period]{.underline}: The contractor shall complete
the work required under this SOW as specified, unless otherwise directed
by the Contracting Officer (CO). If the contractor proposes an earlier
completion date, and the Government accepts the contractor's proposal,
the contractor's proposed completion date shall prevail.

F.1.2 [Type of Contract]{.underline}: This is a firm-fixed-price,
performance-based contract based on a predetermined schedule of fees.
Positive and negative incentives will be applied for performance on a
quarterly basis for timeliness and quality. All other performance
metrics will be measured either semi-annually, or annually.

**G.1. CONTRACT AWARD MEETING**

The contractor shall not commence performance on the tasks in this SOW
until the CO has conducted a kick off meeting or has advised the
contractor that a kick off meeting is waived.

**H.1. GENERAL REQUIREMENTS**

H.1.1 For every task, the contractor shall identify in writing all
necessary subtasks (if any), associated costs by task, together with
associated submilestone dates. The contractor\'s subtask structure shall
be reflected in the technical proposal and detailed project management
plan (PMP).

H.1.2 All written deliverables will be phrased in layperson language.
Statistical and other technical terminology will not be used without
providing a glossary of terms.

**I.1 PERSONNEL**

I.1.1 The contractor shall ensure that medical examinations are
conducted by a graduate of an accredited medical school, who is licensed
to practice in the State where he/she conducts examinations. Excluded
from participation are individuals who are excluded, suspended, or
otherwise barred from participation in the Medicare or Medicaid
programs, or any other Federal or Federally assisted program; whose
license to provide health care services is currently revoked or
suspended by a State licensing authority pursuant to adequate due
process procedures for reasons bearing on professional competence,
professional conduct, or financial integrity; or who, until a final
determination is made, has surrendered such a license while formal
disciplinary proceedings involving professional conduct are pending.
Examiners\' licenses must be clear and unrestricted while performing
examinations under this contract. The contractor shall ensure that
examiners have current medical liability insurance coverage. For States
that maintain lower levels of malpractice insurance requirements for
examiners/dentists, the VA will accept those State levels for the
purposes of this contract. The contractor shall maintain documentation
of their credentialling review on file and make that information
available to the VA for review on demand. The contractor shall check the
status of the examiners on a semi-annual basis to ensure that licensing
has not been revoked or disciplinary proceedings involving professional
conduct are pending.

**J.1 TRAINING\
**

J.1.1 The contractor, in consultation with the VA, shall prepare and
implement a training program for all examiners to provide a basic
overview of VA programs, available sources of veteran assistance, and an
understanding of the core claims adjudication process (what the veteran
may expect after the examination, who makes the decision, and whom to
contact for more information). Information concerning referral to the
VA\'s health care system shall also be provided.

J.1.2 The contractor shall provide orientation and instructions to the
examiners for conducting examinations for VA purposes based on the
requirements provided in the C&P examination worksheets. In addition,
the contractor shall provide training to the examiners to:

-   explain the differences between a VA disability examination protocol
    versus the examination protocol for treatment purposes

-   ensure an appropriate attitude towards veterans and their unique
    circumstances

-   ensure that examiners understand the VA\'s principle of reasonable
    doubt (\"as least as likely as not\") in the application of
    disabilities

-   explain the concept of presumptive diagnoses in view of unique
    circumstances of military service

-   ensure that examiners understand how to assess and document pain.

The contractor shall provide the training materials and the C&P
examination worksheets to each examiner either in paper or electronic
format.

J.1.3 The contractor, in consultation with the VA, shall prepare and
implement a training program for all support staff personnel who will
have routine contact with veterans, to provide a basic overview of the
VA programs, available sources of veteran assistance and an
understanding of the core claims adjudication process (what the veteran
may expect after the examination, who makes the decision, and who to
contact for more information). Information concerning referral to the
VA\'s health care system will also be provided.

**K.1 QUALITY CONTROL**

K.1.1 The contractor shall demonstrate a quality assurance program to
ensure that examination reports comply with the VA requirements before
submission to the VA. The contractor shall take corrective action when
examination deficiencies are identified and return any
corrective/additional information to VA within 14 business days.

**L1. PRIVACY ACT INFORMATION**

L.1.1 The contractor\'s staff will have access to sensitive veterans\'
records. The contractor shall prevent the unauthorized release of
information obtained by employees in the performance of work required by
this contract. The contractor shall ensure that employees are aware of
and receive training, as necessary, on all regulations and laws such as
the Privacy Act that restricts the release of information. Veterans
claims files and all examination reports and testing results are the
property of the VA and the information contained therein is protected
under the Privacy Act. All veteran claims folders forwarded for
copying/scanning must be maintained in locked files while under the care
of the contractor.

**M.1 PHASE-IN PERFORMANCE AND PERIODS OF PERFORMANCE**

M.1.1 Phase-in Performance consists of all the preparation activities,
including but not limited to making capital expenditures, ensuring a
qualified workforce in place, providing appropriate training, and
implementing the information technology support necessary to fully
perform the requirements contained in this statement of work and
contract on May 1, 2003. The contractor shall begin performance of all
requirements under this contract and conduct the Contract Medical
Disability Examinations at all locations on May 1, 2003. The period of
performance for the Phase-in Period will begin at contract award and
last for approximately four months (based on awarding the contract at
the end of December 2002 and start up on May 1 2003. The Base Period
will be a full year and begin on May 1, 2003 and end on April 30, 2004.
The First, Second, Third and Fourth Options periods, as well as any
additional options years awarded, will be one year long. The incentives
will not be applied during the phase-in period. In addition, the
phase-in performance shall be applied to new jurisdictions that the
contractor agrees to assume upon the request of the VA. Upon assuming
new jurisdictions, the contractor shall be provided a phase-in period
not to exceed 6 months to adjust to the additional workload. This is to
provide the contractor adequate time to retain and train any new
employees or examiners necessary to complete the additional work.

**Exhibit No. 1**

**Performance Requirements Summary**

**Standards, Acceptable Levels of Performance (ALPs)**

+---------+--------+--------+--------+--------------------+-----------+
| *       | *      | **Stan | *      | *                  | **Sur     |
| *Task** | *Objec | dard** | *ALP** | *Positive/Negative | veillance |
|         | tive** |        |        | Incentives**       | Method/   |
|         |        |        |        |                    | Measure** |
+---------+--------+--------+--------+--------------------+-----------+
| *       | To     | 35     | 38     | **Positive**:      | Quarterly |
| *C.1.11 | p      | days   | days   |                    | reports   |
| Timeli  | rovide | a      | a      | 33 days or less    | generated |
| ness**. | VA     | verage | verage | average cycle time | by VA\'s  |
| C       | timely | cycle  | cycle  | with at least 66%  | Veterans  |
| omplete | de     | time   | time   | of the workload    | Ex        |
| and     | livery | for    | for    | completed for the  | amination |
| return  | of     | all    | all    | quarter: If this   | Request   |
| exam    | exami  | sites  | sites  | is met for at      | In        |
| ination | nation | com    | co     | least three        | formation |
| reports | r      | bined. | mbined | quarters of the    | System    |
| to VA.  | eports |        | for    | contract year, and | (VERIS).  |
|         | to     |        | the    | the ALP is         | Measured  |
|         | i      |        | qu     | exceeded for       | 30 days   |
|         | mprove |        | arter. | quality for at     | after the |
|         | a      |        | If     | least three        | end of    |
|         | verage |        | this   | quarters of the    | each      |
|         | claims |        | is     | contract year,     | quarter.  |
|         | proc   |        | met,   | then an additional |           |
|         | essing |        | no     | year can be        | Disc      |
|         | timel  |        | po     | awarded.           | repancies |
|         | iness. |        | sitive |                    | will be   |
|         |        |        | or     | **Negative:**      | resolved  |
|         |        |        | ne     |                    | by the VA |
|         |        |        | gative | 39-40 days average | co        |
|         |        |        | ince   | cycle time: 1% of  | ntracting |
|         |        |        | ntives | total invoiced for | officer.  |
|         |        |        | apply. | quarter will be    |           |
|         |        |        |        | deducted.          |           |
|         |        |        |        | Measurement will   |           |
|         |        |        |        | be rounded up to   |           |
|         |        |        |        | the next whole     |           |
|         |        |        |        | number if more     |           |
|         |        |        |        | than .5.           |           |
|         |        |        |        |                    |           |
|         |        |        |        | 41 (or more) days  |           |
|         |        |        |        | average cycle      |           |
|         |        |        |        | time: 2% of total  |           |
|         |        |        |        | invoiced for       |           |
|         |        |        |        | quarter will be    |           |
|         |        |        |        | deducted.          |           |
|         |        |        |        | Measurement will   |           |
|         |        |        |        | be rounded up to   |           |
|         |        |        |        | the next whole     |           |
|         |        |        |        | number if more     |           |
|         |        |        |        | than .5.           |           |
+---------+--------+--------+--------+--------------------+-----------+
| *       | To     | 96%    | 94-96% | **Positive:**      | Quarterly |
| *C.1.12 | p      | qu     | q      |                    | review by |
| Qua     | rovide | ality. | uality | 98% or higher      | VBA       |
| lity**. | exami  |        | acc    | quality. If this   | Medical   |
| Provide | nation |        | ording | is met for at      | Director  |
| exam    | r      |        | to     | least three        | and/or    |
| ination | eports |        | VA\'s  | quarters of the    | board of  |
| reports | that   |        | exami  | contract year, and | three     |
| that    | meet   |        | nation | the timeliness ALP | VACO      |
| meet    | VA\'s  |        | wor    | is exceeded for at | rating    |
| VA\'s   | rating |        | ksheet | least three        | experts   |
| requir  | requir |        | r      | quarters of the    | (or a     |
| ements. | ements |        | equire | contract year,     | comb      |
|         | so     |        | ments. | then an additional | ination). |
|         | that   |        | If     | year can be        | A sample  |
|         | rating |        | this   | awarded.           | size of   |
|         | speci  |        | is     |                    | appr      |
|         | alists |        | met,   | **Negative**:      | oximately |
|         | may    |        | then   |                    | 315       |
|         | use    |        | no     | 92-93% quality: 1% | randomly  |
|         | r      |        | posit  | of the total       | selected  |
|         | eports |        | ive/ne | invoiced for the   | exam      |
|         | to     |        | gative | quarter being      | reports   |
|         | co     |        | ince   | measured will be   | (sample   |
|         | mplete |        | ntives | deducted.          | size can  |
|         | rating |        | apply. |                    | change    |
|         | deci   |        |        | 91% or below: 2%   | depending |
|         | sions. |        |        | of the total       | on number |
|         |        |        |        | invoiced for the   | of exam   |
|         |        |        |        | quarter being      | reports   |
|         |        |        |        | measured will be   | delivered |
|         |        |        |        | deducted.          | in a      |
|         |        |        |        |                    | quarter). |
+---------+--------+--------+--------+--------------------+-----------+
| *       | To     |        |        | **Positive:**      | VERIS     |
| *C.1.13 | ensure |        |        |                    | reports   |
| Report  | that   |        |        | No positive        | generated |
| Suffic  | insuff |        |        | incentives apply.  | on a      |
| iency** | icient |        |        |                    | quarterly |
|         | exami  |        |        | **Negative:**      | basis.    |
| Return  | nation |        |        |                    |           |
| report  | r      |        |        | For each           |           |
| corr    | eports |        |        | insufficient       |           |
| ections | are    |        |        | report not         |           |
| to VA   | re     |        |        | returned to VA     |           |
| within  | turned |        |        | within 14 calendar |           |
| 14      | to VA  |        |        | days, a 5%         |           |
| c       | t      |        |        | deduction of the   |           |
| alendar | imely. |        |        | total invoiced for |           |
| days.   |        |        |        | that exam request  |           |
|         |        |        |        | will apply.        |           |
+---------+--------+--------+--------+--------------------+-----------+
| **C.1.8 | To     | 98% of | 92% of | **Positive:**      | Customer  |
| C       | ensure | the    | the    |                    | Survey    |
| ustomer | that   | time.  | time.  | 93-95% of the time | conducted |
| S       | ve     |        | If     | seen within one    | with VA   |
| atisfac | terans |        | this   | hour: .25% of the  | ongoing   |
| tion**. | are    |        | is     | total invoiced for | t         |
| Examine | seen   |        | met,   | the period being   | hroughout |
| v       | within |        | no     | measured.          | contract  |
| eterans | one    |        | po     |                    | period.   |
| within  | hour   |        | sitive | 96% (or higher) of |           |
| one     | of the |        | or     | the time seen      |           |
| hour of | sch    |        | ne     | within one hour:   |           |
| appo    | eduled |        | gative | .5% of the total   |           |
| intment | appoi  |        | ince   | invoiced for the   |           |
| time.   | ntment |        | ntives | period being       |           |
|         | time.  |        | will   | measured.          |           |
|         |        |        | apply. |                    |           |
|         |        |        |        | **Negative:**      |           |
|         |        |        |        |                    |           |
|         |        |        |        | 85-90% of the time |           |
|         |        |        |        | seen within one    |           |
|         |        |        |        | hour: .25% of the  |           |
|         |        |        |        | total invoiced for |           |
|         |        |        |        | the period will be |           |
|         |        |        |        | deducted.          |           |
|         |        |        |        |                    |           |
|         |        |        |        | 84% and below: .5% |           |
|         |        |        |        | of the total       |           |
|         |        |        |        | invoiced for the   |           |
|         |        |        |        | period will be     |           |
|         |        |        |        | deducted.          |           |
+---------+--------+--------+--------+--------------------+-----------+
| **      | To     | 100%   | 92% of | **Positive:**      | Customer  |
| C.1.12, | ensure | sati   | the    |                    | Survey    |
| C.1.13, | that   | sfied. | time   | 93-95% of the time | conducted |
| and     | ve     |        | sati   | \"very\" satisfied | with VA   |
| C.1.15  | terans |        | sfied. | with contractor\'s | ongoing   |
| C       | are    |        |        | services: .25% of  | t         |
| ustomer | sat    |        |        | the total invoiced | hroughout |
| Satisfa | isfied |        |        | for the period     | contract  |
| ction** | with   |        |        | being measured.    | period.   |
|         | the    |        |        |                    |           |
| Overall | c      |        |        | 96% (or higher) of |           |
| satis   | ontrac |        |        | the time \"very\"  |           |
| faction | tor\'s |        |        | satisfied with the |           |
| with    | se     |        |        | contractor\'s      |           |
| contra  | rvices |        |        | services: .5% of   |           |
| ctor\'s | to     |        |        | the total invoiced |           |
| se      | in     |        |        | for the period     |           |
| rvices. | clude: |        |        | being measured.    |           |
|         | sched  |        |        |                    |           |
|         | uling, |        |        | **Negative:**      |           |
|         | n      |        |        |                    |           |
|         | otific |        |        | 85-90% of the time |           |
|         | ation, |        |        | \"very\"           |           |
|         | and    |        |        | dissatisfied with  |           |
|         | examin |        |        | the contractor\'s  |           |
|         | ation. |        |        | services: .25% of  |           |
|         |        |        |        | the total invoiced |           |
|         |        |        |        | for the period     |           |
|         |        |        |        | being measured     |           |
|         |        |        |        | will be deducted.  |           |
|         |        |        |        |                    |           |
|         |        |        |        | 84% (and below) of |           |
|         |        |        |        | the time \"very\"  |           |
|         |        |        |        | dissatisfied with  |           |
|         |        |        |        | the contractor\'s  |           |
|         |        |        |        | services: .5% of   |           |
|         |        |        |        | the total invoiced |           |
|         |        |        |        | for the period     |           |
|         |        |        |        | being measured     |           |
|         |        |        |        | will be deducted.  |           |
+---------+--------+--------+--------+--------------------+-----------+

**Exhibit No. 2**

**Quality Assurance Surveillance Plan**

**For Contract XXXXX**

I.  Objective

This plan provides a quality surveillance strategy for disability
examinations performed for the US Department of Veterans Affairs (VA),
Veterans Benefits Administration (VBA). The primary intent of the plan
is to provide a basis for the contracting officer\'s technical
representative\'s (COTR) evaluation of performance quality. Oversight of
contractor performance will assure contract quality and consistency of
services provided to VBA and the veteran. The plan will also afford the
COTR a proactive mechanism to preclude major deficiencies in performance
and provide input for annual past performance evaluations.

II. Performance Indicators (Measures)

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a.  Timeliness. The COTR will determine whether the contractor has
    consistently satisfied the acceptable level of performance per
    contractual requirements. The timeliness standard for completing
    examination requests is specified in C.1.11.

b.  Quality. The COTR will determine whether the contractor has
    consistently satisfied the acceptable level of performance for
    documenting examination reports per VA examination worksheet
    specifications. The quality standard for ensuring that all
    examination reports are compliant with the VA examination worksheets
    is specified in C.1.12.

c.  Report Corrections. The COTR will determine whether the contractor
    has consistently satisfied the acceptable level of performance for
    returning insufficient reports to VA in a timely manner. The
    standard for returning insufficient examination reports to VA is in
    C.1.13.

d.  Customer Satisfaction. The COTR will determine whether the
    contractor has consistently satisfied the acceptable level of
    performance for ensuring that veterans are seen by physicians within
    one hour of appointment time, and that veterans\' are satisfied with
    the contractor\'s services. The standards for customer satisfaction
    are found in C.1.3, C.1.6, C.1.8, C.1.14, C.1.17, and C.1.18.

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III. Evaluation Methods

The COTR will perform evaluations based on the indicators in paragraph
II of this plan. The COTR will initiate the following surveillance
techniques.

a.  Random inspections. The COTR will perform random visual inspections
    at least once a year at all of the contractor\'s sites that perform
    functions for VA under this contract. A minimum of one site will be
    included in each inspection, unless specific areas have been
    targeted for surveillance. A targeted area is one that has received
    multiple complaints or that needs special attention by the
    contractor for any reason. The COTR will inform the contractor of
    any discrepancies found against performance standards. The COTR will
    maintain records of all inspections and provide a copy of any report
    to the contractor.

b.  Quarterly quality reviews. The VBA Medical Director will conduct a
    quarterly quality review of a random sample of the contractor\'s
    completed examination reports based on the requirements of the VA
    examination worksheets. The VBA Medical Director will share the
    results of the reviews with the COTR and contractor and be available
    to the contractor to explain the findings with the contractor\'s
    employees.

c.  Veterans Examination Request Information System (VERIS). The COTR
    will generate quarterly reports for quality and timeliness from the
    VBA Intranet tool that is used by rating specialists to enter
    examination requests and record timeliness and quality information.
    This tool measures the timeliness based on date that the request is
    actually sent to the contractor, to the date it is logged in as
    complete and available to VBA. The contractor provides the
    completion date to be entered into the application, but the
    completed examination report must be delivered (or posted) to VA on
    that date.

d.  Customer Satisfaction. An annual customer satisfaction survey is
    performed. An independent contractor will be responsible for
    receiving the completed questionnaires and tabulating the results
    for the COTR\'s review. Quarterly results will also be provided to
    the contractor so that any customer satisfaction area requiring
    attention can be addressed by the contractor. Veterans\' responses
    to these questions will become the basis for the COTR to determine
    if incentives or deductions are to be applied according to the ALPs.

**Exhibit No. 3**

**Questions/Answers**

+-----------------------------------------------------------------------+
| **CONTRACT MEDICAL DISABILITY EXAMS**                                 |
|                                                                       |
| ## RFP                                                                |
|                                                                       |
| ### QUESTIONS/ANSWERS                                                 |
+-----------------------------------------------------------------------+

**[GENERAL ACQUISITION OUESTIONS:]{.underline}**

**[INFORMATION TECHNOLOGY AND COMMUNICATIONS:]{.underline}**

1\. What kind of e-mail system would be in use by the VA for the
project?

The Veterans Benefits Administration (VBA) uses Microsoft Exchange 4.0
electronic mail system as its \"departmental\" messaging system. We have
a Simple Mail Transfer Protocol (SMTP) gateway in operation which
permits electronic messages to be sent from VBA personnel to external
mail boxes on the Internet and visa versa. At the present time, there
are no security measures in place to protect the privacy of data
transmitted via electronic mail. For this project, secure transmission
of data is necessary due to the private nature of the data.

2\. Is it MIME compliant for attachments?

Yes, according to Microsoft\'s Technet, Exchange 4.0 supports
Multipurpose Internet Mail Extensions (MIME) and is MIME-compliant.

3\. Do you expect WAN (Wide Area Network) access to our scheduling
system?

Yes, all participating VBA Regional Offices will need on-line access to
the vendor\'s scheduling system and exam request facilities. The vendor
must

> **present a fully functional connectivity solution that includes all
> access components. The VBA has an internal use WAN, called the
> Integrated Data Communications Utility (IDCU), which is a private,
> packet switched network.**

4\. If yes, how many simultaneous users?

VBA estimates 530 potential total users over the life of the contract.
About 300 users (all current rating specialists, hearing officers, and a
station project coordinator at each site) will require access from their
desktop in the initial pilot. We estimate about 50 simultaneous users
during peak production hours.

5\. If you desire modem access, how many simultaneous users?

VBA does not require modems as a connection strategy and it is not
preferred; however, it is recognized as a reasonable approach to the
requirement. If modems are proposed, then the vendor must provide each
user with a modem or access to a modem pool at the VBA site as well as
the vendor\'s host site. The requirement is that VBA personnel must be
able to conduct business with the contract provider without having to
leave their desktop workstation and go to another workstation. Of the
estimated 300 Rating Specialist and Decision Review Officers who will
participate in the study, we project that there will be about 50
simultaneous users during production hours.

6\. Would you prefer WEB browser access with password protection? Do the
claims staff use a browser, and if so, what type and version?

VBA prefers a WEB based technical solution. Password protection and
encrypted transmission of data is necessary to ensure the privacy of
data. The VBA standard browser is Microsoft Internet Explorer 5.5 in
conjunction with Microsoft TCP/IP for Windows 95 and Softronic\'s
Softerm 4.00.02 for terminal emulation.

7\. How will the examination requests be sent to the contractor?

VBA rating specialists use an Intranet tool called VERIS (Veterans
Examination Request Information System). All new requests are identified
as status \"1\" and are rolled up by the application every morning,
encrypted and e-mailed to the contractor over the Internet in a text
file format. A back up plan will also need to be developed by the
contractor and VBA when Internet e-mail is not available due to
technical difficulties.

8\. Is toll-free access expected for Veterans to call on us?

Yes. We would expect toll-free service for veterans to contact the
contractor with questions pertaining to their scheduled examinations
during normal business hours.

9\. Would the VA make calls to us at their expense or also expect
toll-free service?

No. VA calls will be at government expense.

10\. Would most communication with the VA for scheduling purposes be
performed via computer, phone or fax?

Routine scheduling would be by computer.

**[BILLING:]{.underline}**

11\. How many examinations will be included in each order?

It depends. Daily examination requests have been as low as 200 and as
high as 400 due to VBA\'s workload peaks. We would expect this trend to
remain for at least the next two years, but would not expect it to drop
to below 200 per day.

12\. In what intervals or batches should examinations be billed?

Invoices shall be submitted monthly or bi-monthly to the VBA COTR and
project manager in an electronic format.

13\. Do you have sample invoices that can be furnished?

No.

14\. What sort of supporting documentation would accompany a fund
transfer?

The paying office sends the transfer to your bank along with the invoice
number, contract number, and dollar amount. The bank notifies their
customer, i.e. you. It was recommended that you talk to the ACB
coordinator at your bank to find out the exact details of how they
handle it.

CONSULTANT RECRUITING/SCHEDULING/TRAINING and OPERATIONS:

15\. Can you provide the most common worksheets requested?

> **Yes. Below is the volume of the twelve most common worksheets
> requested during the period May 1, 2001 through April 30, 2002:**

  ------------------------------------------- ---------------------------
  **Worksheet**                               **Volume**

  **Joints**                                  **6,001**

  **Hearing**                                 **4,635**

  **Spine**                                   **4,468**

  **General Medical**                         **4,388**

  **Diabetes Mellitus**                       **2,781**

  **Mental Disorders**                        **2,034**

  **Eye Exam**                                **1,615**

  **PTSD (To Establish)**                     **1,605**

  **Hypertension**                            **1,475**

  **Feet**                                    **1,370**

  **Skin Diseases**                           **1,238**

  **PTSD (Follow Up Exam)**                   **1,232**
  ------------------------------------------- ---------------------------

16\. What is the percentage of exams that require more than one
physician?

> **With the exception of specialist examinations (for which separate
> billing is provided) a single physician should be able to complete all
> required examination worksheets.**

17\. Please clarify what percentage of examination requests are
multi-exams.

Each examination requests generally equates to 1.3 examinations to
complete the request.

18\. How many medical records in pages are provided on average?

Claims folder (original) containing available medical records will be
provided. Volume of medical records will range significantly depending
on circumstances of the claim including treatment history, and whether
the examination is for an original claim, reopened claim or appellate
issue. Currently, claims folders are sent for at least psychiatric
evaluations, requests for medical opinions, appellate review and most
requests for specialist reviews. Some claims folders can be several
inches thick, but only the medical records, and other pertinent
documentation, will need to be scanned.

19\. Will the records be in paper form, microfiche, or electronic?

Records will be provided in paper form (originals requiring return to
the sending station).

20\. How long are records to be retained?

If the question refers to VA records submitted for review, they should
be returned as soon as the examiner has completed his report but no
later than five (5) days after completion of the examination report. If
the question refers to how long the Contractor should maintain an
examination report and supporting data, the answer is a minimum of one
year.

21\. Are the VA records that are to be forwarded to the contractor the
original records? If so, does the VA or contractor assume responsibility
if they are lost in the mail? Also, following the examinations, is the
VA or the contractor the custodian of the examination reports?

Yes, original records will be furnished. The contractor would not be
responsible for records lost in the mail. However, protecting records in
the contractor\'s possession including the privacy of those records
would be considered a contractor responsibility, and failure to do so
would be considered performance deficiency. The examination reports must
be maintained by the contractor for a period of one year. The VA will
print the reports received, associate the report with the veteran\'s
claims folder where it will permanently reside. The contractor is not
considered the custodian of the record. The VA is the custodian and any
requests directed to the contractor for claimant information should be
directed to the regional office of record for processing.

22\. Are the tests that are included in the exam to be performed prior
to the exam? Is the examining physician expected to review test results
such as X-rays?

Scheduling of tests will be left to contractor discretion. In some
instances a determination of required test may not be made until after
the physician has conducted an examination, but yes, the physician\'s
findings and diagnosis should include a review of test results.

23\. If further testing is required, is the patient to return to the
examining physician for further review?

As needed only (often a physician should be able to complete his report
with review of the test results), but if further physician review
(examination) is required, it should be by the same physician if
possible.

24\. Are any of the tests to be performed at VA facilities?

No.

25\. You ask that 7 days be allowed for scheduling. Do you have a window
that you prefer?

> **The veteran must be given timely notification of the scheduled
> appointment.**

26\. From compliance and incentive standpoint, does the clock start from
the time of the first call for an examination by the VA, the date of the
exam, or when labs are finished? (Realize that if an exam is for example
scheduled in 14 days, and lab/X-rays are required, that to meet the
optimum time frame, there is very little time to produce the report.
Certain studies such as MRI\'s, cardiac studies and others might not be
able to be scheduled the same day, and require several days for
results.)

> **The clock starts from the time the contractor receives the daily
> file containing the examination requests until the date the VA
> receives the completed examination report. We recognized that in some
> instances examinations may take longer to process and allow for that
> by measuring based on [AVERAGE]{.underline} processing days.**

27\. Are we expected to notify the Veterans of the examination by mail,
phone or both? How is it currently done?

The contractor may use mail, phone, e-mail or a combination of all to
notify the veteran of the examination date and time. We prefer a
combination so that \"no shows\" can be kept to a minimum.

28\. Should no-shows and late cancels be automatically rescheduled? With
or without VA knowledge and/or consent?

> **One reschedule is allowed. If the veteran is a no show, and does not
> contact the contractor the day after the scheduled appointment to
> request a reschedule, then the regional office must be notified by
> e-mail that the veteran was a no show and no further attempt to
> contact the veteran is necessary. However, if the veteran does contact
> the contractor and request to be rescheduled, then one reschedule is
> allowed. The contractor may also \"code\" this request as a
> \"reschedule\" so that the examination request cycle time is not
> counted against the contractor for accommodating the veteran.**

29\. If a veteran calls in advance to rearrange an examination within a
reasonable period (e.g. one week), is this permissible?

Yes.

30\. Are we expected to determine service connectedness as well as
diagnosis?

No. The determination of service connection is the responsibility of the
VBA rating specialist. You may however, be asked to offer specific
opinions such as \"are current symptoms related to condition
\[specified\] documented during military service?\" Or, \"is the
condition as least as likely or not related to service?\" (Service
medical records and available post service treatment records would be
provided for review.) Or, \"is there a causal relationship between a
service connected left knee condition and current low back complaints?\"

31\. Please discuss the nature of the disability exams; philosophy,
reference material used by physicians, length of exam, amount of
narrative, etc.

> **Disability examinations are to be approached in a positive manner.
> When issues arise where reasonable doubt exists, that doubt should be
> decided in the veteran\'s favor. The examination in addition to
> etiological, anatomical, pathological, laboratory and prognostic data
> required for ordinary medical classification, should fully describe
> the effects of disability upon the person\'s ordinary activity.**

The basic guideline for examinations is the Compensation and Pension
Examination Worksheets. The length of examination should be governed by
the time required to obtain the information specified in the relevant
worksheet, including appropriate history and complaints. Concise
narrative, including required findings, and any other information
directly pertinent to

> **the issue is preferred. Unnecessarily redundant or expansive
> narratives should be avoided.**

32\. If the veteran asks for a copy of the report, should it be
provided?

No. The veteran should be advised to obtain a copy from the VA regional
office handling the veteran\'s claim.

33\. If a release signed by the veteran and/or subpoena is received for
the report, should it be provided with or without the VA knowledge
and/or consent?

No. The VA is the custodian of the record and all requests should be
forwarded to the regional office of record for response.

34\. Should the consultants be specifically proscribed as to offering
treatment for the veterans that they examine?

If treatment is necessary, then the regional office should be notified
so that treatment can be arranged at the closest VA medical center or
clinic. If urgent care is needed, then a referral can be made with
notification to VA for follow up.

35\. Do these examinations become part of the Veteran\'s medical record
file?

They become a permanent part of the Veteran\'s VA claims folder. They
will be available for appellate review by the Board of Veterans Appeal
(BVA), U.S. Court for Veterans Appeals, and regional office review in
conjunction with any future reviews (either based on a reopened claim or
other future review). They will not be routinely forwarded to VA\'s
Veterans Health Administration unless a VA medical center requests a
copy of the report.

36\. While examination reports are to be conveyed electronically, does
the VA desire a hard copy as well to be mailed?

No.

37\. Copies of labs, photos, X-rays and other studies would be mailed
separately from the electronically submitted reports. Is this what is
expected?

No. It is preferred that they be transmitted in .pdf format along with
the examination report electronically. The actual x-rays are not
routinely required; the narrative report (reading) is sufficient, unless
otherwise specified.

38\. Is there an average size in words or pages of a report for given
specialties?

No. We seek concise reports that convey all the required information per
the examination worksheets.

39\. Do you have some sample reports that demonstrate your concept of
excellence?

No. We believe the Compensation and Pension Examination Worksheets are
the best \"guide\" to the information necessary to present an excellent
examination report.

ADMINISTRATIVE and OTHER:

40\. What are the VA\'s current internal costs per examination? Do these
include laboratory and x-ray?

The internal cost of conducting an examination for disability evaluation
purposes is not yet available.

41\. What are the main problems currently faced with the internal system
now in place?

Current problems include uneven examination quality and processing
timeliness.

42\. Do you intend to increase the size of the contract during the
course of it?

Not at the present time.

43\. Does the government anticipate an immediate full caseload from the
ten regional office and their Benefits Delivery at Discharge (BDD) sites
as of May 1, 2003?

Yes. The contractor should be ready to take the full caseload by this
date.

44\. Will the government provide relevant training materials and/or
collaborative consultation to assist us in developing proper training on
the VA system, and its policies and requirements?

Yes. Existing materials developed to assist VA physicians will be
reviewed and adapted for this purpose. Additional information required
to introduce physicians and others to the VA, our programs, and
resources will be developed and provided.

45\. Do you have any estimates of the percent of veterans who are
entitled to and who claim travel allowance to attend examinations, and
the average cost for those who are reimbursed?

Most veterans would be eligible for travel allowance for attending
examinations. The average cost will depend greatly on a contractor\'s
ability to schedule examinations relatively close to the veteran\'s home
of record, since payments are based on rate per mile traveled.

46\. How many VA staff would we be likely to interact with on a regular
basis?

Each of the ten regional offices has one examination coordinator who is
the primary contact for the contractor for inquiries and clarification
as it pertains to the daily workload file. In addition, a VBA project
manager is assigned, as well as a COTR who the contractor will be in
routine contact.

47\. Do hearing exams have to be performed with all general medical
examinations?

> **No. A specific audiology examination would only be required if
> hearing loss was specified as a condition to be examined, or if during
> the general clinical assessment, hearing impairment was established or
> suspected. Hearing examinations must be performed by a licensed
> audiologist using the Maryland CNC test.**

48\. What percentage of non-specialist exams require a specialist exam?

For examinations in areas other than psychiatry, dental, ophthalmology,
audiology, and neurology, specialty requests will be the exception and
not the norm. While a specialist will not be required for all
neurological issues, specialists will be required in this area more
often than not. However, for example, when checking for peripheral
neuropathy as a complication of diabetes, a specialist will not
generally be required. Usually, in other areas, specialist examinations
will be requested when a case has been appealed and a specialist
examination is directed by the Board of Veterans Appeals, or when there
is conflicting medical evidence of record which requires resolution.
Specific percentages have not been documented.

49\. Is additional medical opinion/recommendation such as apportionment,
causation and return to work status required in each report, and if so,
is it included in the unit price.

Routine information required in each worksheet will be included in the
examination price. Medical opinions, questions that the physician can
respond to based on examination of the veteran, not requiring extensive
review of medical records will also be included in the basic exam price.
A separate charge may be added for specific requested \"independent
medical opinions\" requiring review of the available medical records and
a formal written opinion including citation of the pertinent facts found
on the medical record review.

50. The contractor must bear the cost of postage for the customer survey
    cards. Do they have to be mailed via first class postage to the
    independent contractor?

No, as long as the cards can be received by the independent contractor
within a two-week period once placed into the US Postal Service system
by the veteran.

**Exhibit No. 4**

**Compensation and Pension Examination Worksheets**

**GENERAL MEDICAL EXAMINATION**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

[Narrative:]{.underline} This is a comprehensive base-line or screening
examination for all body systems, not just specific conditions claimed
by the veteran. It is often the initial post-discharge examination of a
veteran requested by the Compensation and Pension Service for disability
compensation purposes. As a screening examination, it is not meant to
elicit the detailed information about specific conditions that is
necessary for rating purposes. **Therefore, all claimed conditions, and
any** **found or suspected conditions that were not claimed, should be
addressed by referring to and following all appropriate worksheets, in
addition to this one, to assure that the examination for each condition
provides information adequate for rating purposes**. This does not
require that a medical specialist conduct examinations based on other
worksheets, except in the case of vision and hearing problems, mental
disorders, or especially complex or unusual problems. **Vision, hearing,
and mental disorder examinations must be conducted by a specialist**.
The examiner may request any additional studies or examinations needed
for proper diagnosis and evaluation (see other worksheets for guidance).
All important negatives should be reported. The regional office may also
request a general medical examination as evidence for
nonservice-connected disability pension claims or for claimed
entitlement to individual unemployability benefits in service-connected
disability compensation claims. Barring unusual problems, examinations
for pension should generally be adequate if only this general worksheet
is followed.

A. **Review of Medical Records:** Indicate whether the C-file was
reviewed.

B. **Medical History (Subjective Complaints):**

1.  Discuss: Whether an injury or disease that is found [occurred during
    active service, before active service, or after active
    service]{.underline}. To the extent possible, describe the
    circumstances, dates, specific injury or disease that occurred,
    treatment, follow-up, and residuals. If the injury or disease
    occurred [before active service]{.underline}, describe any worsening
    of residuals due to being in military service. Describe current
    symptoms and treatment.

2.  Occupational history (for [pension]{.underline} and [individual
    unemployability]{.underline} claims): Obtain the name and address of
    employers (list most current first), type of occupation, employment
    dates, and wages for last 12 months. If any time was lost from work
    in the past 12-month period, please describe the reason and extent
    of time lost.

3.  Describe details of current treatment, conditions being treated, and
    side effects of treatment.

4.  Describe all surgery and hospitalizations in and after service with
    approximate dates.

5.  If a malignant neoplasm is or was present, provide:

> a\. Date of confirmed diagnosis.

b.  Date of the last surgical, X-ray, antineoplastic chemotherapy,
    radiation, or other therapeutic procedure.

c.  State expected date treatment regimen is to be completed.

d.  If treatment is already completed, provide date of last treatment.

e.  If treatment is already completed, fully describe residuals.

**C. Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings: The
examiner should incorporate results of all ancillary studies into the
final diagnoses.

1.  [VS]{.underline}: Heart rate, blood pressure (see #13 below),
    respirations, height, weight, maximum weight in past year, weight
    change in past year, body build, and state of nutrition.

2.  [Dominant hand]{.underline}: Indicate the dominant hand and how this
    was determined, e.g., writes, eats, combs hair with that hand.

3.  [Posture and gait]{.underline}: Describe abnormality and reason for
    it. Describe any ambulatory aids.

4.  [Skin, including appendages]{.underline}: If abnormal, describe
    appearance, location, extent of lesions. If there are laceration or
    burn scars, describe the location, exact measurements (cm. x cm.),
    shape, depression, type of tissue loss, adherence, and tenderness.
    For each burn scar, state if due to a 2nd or 3rd degree burn.
    Describe any limitation of activity or limitation of motion due to
    scarring or other skin lesions. **NOTE:** If there are disfiguring
    scars (of face, head, or neck), obtain [color]{.underline}
    [photographs]{.underline} of the affected area(s) to submit with the
    examination report.

5.  [Hemic and Lymphatic:]{.underline} Describe adenopathy, tenderness,
    suppuration, edema, pallor, etc.

6.  [Head and face]{.underline}: Describe scars, skin lesions,
    deformities, etc., as discussed under item #4.

7.  [Eyes]{.underline}: Describe external eye, pupil reaction, eye
    movements.

8.  [Ears]{.underline}: Describe canals, drums, perforations, discharge.

9.  [Nose, sinuses, mouth and throat]{.underline}: Include gross dental
    findings. For sinusitis, describe headaches, pain, episodes of
    incapacitation, frequency and duration of antibiotic treatment.

10. [Neck]{.underline}: Describe lymph nodes, thyroid, etc.

11. [Chest]{.underline}: Inspection, palpation, percussion,
    auscultation. Describe respiratory symptoms and effect on daily
    activities, e.g., how far the veteran can walk, how many flights of
    stairs veterans can climb. If a respiratory condition is claimed or
    suspected, refer to appropriate worksheet(s). Most respiratory
    conditions will require PFT's, including post-bronchodilation
    studies. Describe in detail any treatment for pulmonary disease.

12. [Breast]{.underline}: Describe masses, scars, nipple discharge, skin
    abnormalities. Give date of last mammogram, if any. Describe any
    breast surgery (with approximate date) and residuals.

13. [Cardiovascular]{.underline} : NOTE: If there is evidence of a
    cardiovascular disease, or one is claimed, refer to appropriate
    worksheet(s).

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a.  Record pulse, quality of heart sounds, abnormal heart sounds,
    arrhythmias. Describe symptoms and treatment for any cardiovascular
    condition, including peripheral arterial and venous disease. Give
    NYHA classification of heart disease. A determination of METs by
    exercise testing may be required for certain cardiovascular
    conditions, and an estimation of METS may be required if exercise
    testing cannot be conducted for medical reasons. (See the
    cardiovascular worksheets for further guidance.)

b.  Describe the status of peripheral vessels and pulses. Describe
    edema, stasis pigmentation or eczema, ulcers, or other skin or nail
    abnormalities. Describe varicose veins, including extent to which
    any resulting edema is relieved by elevation of extremity. Examine
    for evidence of residuals of cold injury when indicated. See and
    follow special cold injury examination worksheet if there is a
    history of cold exposure in service and the special cold injury
    examination has not been previously done.

c.  **Blood Pressure:** (Per the rating schedule, hypertension means
    that the diastolic blood pressure is predominantly 90mm. or greater,
    and isolated systolic hypertension means that the systolic blood
    pressure is predominantly 160mm. or greater with a diastolic blood
    pressure of less than 90mm.)

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1.  If the diagnosis of hypertension has not been previously
    established, and it is a claimed issue, B.P. readings
    [must]{.underline} be taken two or more times on each of at least
    three different days.

2.  If hypertension has been previously diagnosed and is claimed, but
    the claimant is not on treatment, B.P. readings [must]{.underline}
    be taken two or more times on at least three different days.

3.  If hypertension has been previously diagnosed, and the claimant is
    on treatment, take three blood pressure readings on the day of the
    examination.

4.  If hypertension has not been claimed, take three blood pressure
    readings on the day of the examination. If they are suggestive of
    hypertension or are borderline, readings [must]{.underline} be taken
    two or more times on at least two additional days to rule
    hypertension in or out.

5.  In the diagnostic summary, state whether hypertension is ruled in or
    out after completing these B.P. measurements. Describe treatment for
    hypertension and side effects. If hypertensive heart disease is
    suspected or found, follow worksheet for Heart.

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14. [Abdomen]{.underline}: Inspection, auscultation, palpation,
    percussion. Describe any organ enlargement, ventral hernia, mass,
    tenderness, etc.

15. [Genital/rectal (male)]{.underline}: Inspection and palpation of
    penis, testicles, epididymis, and spermatic cord. If there is a
    hernia, describe type, location, size, whether complete, reducible,
    recurrent, supported by truss or belt, and whether or not operable.
    Describe anal fissures, hemorrhoids, ulcerations, etc. Include
    digital exam of rectal walls and prostate.

16. [Genital/rectal (female)]{.underline}: Pelvic exam, including
    inspection of introitus, vagina, and cervix, palpation of labia,
    vagina, cervix, uterus, adnexa, and ovaries, rectal exam. Do Pap
    smear if none within past year. If unable to conduct an examination
    and Pap smear, or if there is a severe or complex problem, refer to
    a specialist.

17. [Musculoskeletal]{.underline}:

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a.  For all joint or muscle disorders, state each muscle and joint
    affected.

b.  Separately examine and describe in detail each affected joint.
    Measure active and passive range of motion in degrees using a
    goniometer. In addition, provide an assessment of the effect on
    range of motion and joint function of pain, weakness, fatigue, or
    incoordination following repetitive use or during flare-ups. (See
    the appropriate musculoskeletal worksheet for more detail.) NOTE:
    The diagnosis of [degenerative or traumatic arthritis of any joint
    requires X-ray confirmation]{.underline}, but once confirmed by
    X-ray, either in service or after service, no further X-rays of that
    joint are required for disability evaluation purposes.

c.  Describe swelling, effusion, tenderness, muscle spasm, joint laxity,
    muscle atrophy, fibrous or bony residual of fracture. If joint is
    ankylosed, describe the position and angle of fixation.

d.  Describe any mechanical aids used by veteran.

e.  If foot problems exist, also describe objective evidence of pain at
    rest and on manipulation, rigidity, spasm, circulatory disturbance,
    swelling, callus, loss of strength, and whether condition is
    acquired or congenital.

f.  If there is amputation of a part, see the appropriate worksheet.

g.  With disc disease, also describe any neurological findings.

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```
18. [Endocrine]{.underline}: Describe signs and symptoms of any
    endocrine disease, effects on other body systems, and current and
    past treatment. See endocrine worksheets for further guidance.

19. [Neurological]{.underline}: Assess orientation and memory, gait,
    stance, and coordination, cranial nerve functions. Assess deep
    tendon reflexes, pain, touch, temperature, vibration, and position,
    motor and sensory status of peripheral nerves. If neurological
    abnormalities are found on examination, or there is a history of
    seizures, refer to appropriate worksheet.

20. [Psychiatric]{.underline}: Describe behavior, comprehension,
    coherence of response, emotional reaction, signs of tension and
    effects on social and occupational functioning. (This is meant to be
    a brief screening examination. If a mental disorder is [claimed, or
    suspected based on the screening]{.underline}, an examination for
    diagnosis and assessment should be conducted by a psychiatrist or
    psychologist.) State whether the veteran is capable of managing his
    or her benefit payments in his or her own best interests without
    restriction. (A physical disability which prevents the veteran from
    attending to financial matters in person is not a proper basis for a
    finding of incompetency unless the veteran is, by reason of that
    disability, incapable of directing someone else in handling the
    individual\'s financial affairs.)

D. **Diagnostic and Clinical Tests:**

1.  Include results of all diagnostic and clinical tests conducted in
    the examination report.

2.  Review all test results before providing the summary and diagnosis.

3.  Follow additional worksheets, as appropriate.

E. **Diagnosis:** Provide a summary list of all disabilities diagnosed.
Include an interpretation of the results of all diagnostic and other
tests conducted in the final summary and diagnosis. For each condition
diagnosed, describe its effect on the veteran\'s usual occupation and
daily activities.

Signature: Date:

Compensation and Pension Examination

**BONES (FRACTURES AND BONE DISEASE)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Describe details of any injury, episodes of osteomyelitis, or
surgery.

2\. Symptoms of pain, weakness, stiffness, swelling, heat, redness,
drainage, instability or

giving way, \"locking,\" abnormal motion, etc.

3\. Treatment: medication type, dose, frequency, response, and side
effects; other

treatment.

4\. If there are periods of flare-up of bone disease:

a\. State their severity, frequency, and duration.

b\. Name the precipitating and alleviating factors.

c\. Estimate to what extent, if any, they affect functional impairment
during the

flare-up.

5\. Is there current active infection? If not, when was the last active
infection? How was

it determined?

6\. Describe whether crutches, brace, cane, corrective shoes, etc., are
needed.

7\. Are there constitutional symptoms of bone disease?

8\. Describe the effects of the condition on the veteran\'s usual
occupation and daily

activities.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the disability being
examined and fully

describe current findings:

1\. Describe objective evidence of deformity, angulation, false motion,
shortening, intra-

articular involvement, etc.

2\. Malunion, nonunion, any loose motion, false joint.

3\. Tenderness, drainage, edema, painful motion, weakness, redness,
heat.

4\. For weight bearing joints (hip, knee, ankle), describe gait and
functional limitations on

standing and walking. Describe any callosities, breakdown, or unusual
shoe wear

pattern that would indicate abnormal weight bearing.

5\. If ankylosis is present, describe the position of the bones of the
joint in relationship to

one another (in degrees of flexion, external rotation, etc.), and state
whether the

ankylosis is stable and pain free.

6\. With joint involvement, [a detailed assessment of each affected
joint is required]{.underline}.

**Note:** See worksheet on Shoulder, Elbow, Wrist, Hip, Knee, and Ankle
for normal

range of motion of those joints.

a\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance.

b\. If the joint is painful on motion, state at what point in the range
of motion pain

begins and ends.

c\. State to what extent, if any, the range of motion or function is
[additionally]{.underline}

[limited]{.underline} by pain, fatigue, weakness, or lack of endurance.
If more than one of

these is present, state, if possible, which has the major functional
impact.

7\. If shortening of the leg may be present, measure the leg length from
the anterior

superior iliac spine to the medial malleolus.

8\. Are there constitutional signs of bone disease - anemia, weight
loss, fever, debility,

amyloid liver, etc.?

D. **Diagnostic and Clinical Tests:**

1\. As indicated: X-rays, including special views or weight bearing
films, MRI,

arthrogram, diagnostic arthroscopy. **Note:** The diagnosis of
degenerative arthritis or

post-traumatic arthritis of a joint requires X-ray confirmation. Once
the diagnosis has

been confirmed in a joint, further X-rays of that joint are not
required.

2\. For osteomyelitis, state whether there is an involucrum, sequestrum,
or draining sinus.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

**E. Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**FIBROMYALGIA**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

Narrative: For VA compensation purposes, the diagnosis of fibromyalgia
(sometimes called fibrositis, primary fibromyalgia syndrome, or
myofascial pain syndrome) requires the presence of widespread
musculoskeletal pain and tender points. Additional findings may also be
present: fatigue, sleep disturbance, stiffness, paresthesias, headache,
irritable bowel symptoms, depression, anxiety, or Raynaud\'s-like
symptoms. Widespread pain is defined as pain in both the left and right
sides of the body, that is both above and below the waist, and that
affects both the axial skeleton (i.e., cervical spine, anterior chest,
thoracic spine, or low back) and the extremities. Rule out other
diagnostic entities that may be responsible for the symptomatology
presented.

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Date of onset of symptoms, date of diagnosis (if known).

2\. What precipitates and alleviates symptoms?

3\. Location, severity, frequency of any musculoskeletal pain,
stiffness, or muscle

weakness, whether episodic or constant, and what their effects are on
daily

activities

4\. Unexplained fatigue, sleep disturbances.

5\. GI symptoms.

6\. Treatment, (type, duration, response). Has treatment been
continuous?

7\. Is there depression or anxiety?

8\. Lost time from work?

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:
(Please incorporate all

ancillary study results into the final diagnosis.)

1\. Is the condition currently active or in remission?

2\. Musculoskeletal areas involved.

3\. Trigger or tender points.

4\. Muscle strength in involved areas.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**RESIDUALS OF AMPUTATIONS**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. The location of the amputation site.

2\. If symptoms exist, describe precipitating factors, aggravating
factors, alleviating

factors, alleviating medications, frequency, severity, and duration.

**C. Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Swelling, deformity, tenderness of stump.

2\. Skin, including scar.

3\. Circulation.

4\. Muscles

5\. Describe any limited motion or instability in the joint above the
amputation site.

6\. [A detailed assessment of each affected joint is
required]{.underline}.

a\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance.

b\. If the joint is painful on motion, state at what point in the range
of motion pain

begins and ends.

c\. State to what extent, if any, the range of motion or function is
[additionally]{.underline}

limited by pain, fatigue, weakness, or lack of endurance. If more than
one of

these is present, state, if possible, which has the major functional
impact.

7\. Bones

8\. Length of stump

9\. Neuroma, if present

10\. Is amputation of lower extremity improvable by prosthesis
controlled by natural knee

action?

**Measurement of the Stump:**

The stump of an amputated [thigh]{.underline} 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.

The stump of an amputated [leg below the knee]{.underline} must be
measured from the insertion of the internal hamstring muscles to the
bony end of the stump with the patient recumbent and the leg flexed at
90 degrees.

The stump of an amputated [arm]{.underline} should 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.

The stump of an amputated [forearm]{.underline} should 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.

Amputations of [fingers]{.underline} should be described as through 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.

Complete or partial loss of [toes]{.underline} or [metatarsal or tarsal
bones]{.underline} should be described as in the subparagraph 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.

D. **Diagnostic and Clinical Tests:**

1\. X-ray if exact amputation level is not of record.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Amputations must be described in accordance with the following levels:

1\. ARM:

a\. Disarticulation

b\. Amputation above insertion of deltoid muscle.

c\. Amputation below insertion of deltoid muscle.

2\. FOREARM:

a\. Above radial insertion of pronator teres (function is best indicator
of disability).

b\. Below insertion of pronator teres.

3\. THIGH:

a\. Disarticulation, with loss of extrinsic pelvic girdle muscles.

b\. Amputation of upper, middle or lower third, always measured from
perineum to

the bony 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.

4\. LEG:

a\. Give level of amputation and condition of stump.

b\. State whether this level permits a satisfactory prosthesis.

c\. Describe any stump defects (e.g., painful neuroma or circulatory
disturbance).

Signature: Date:

Compensation and Pension Examination

**JOINTS (SHOULDER, ELBOW, WRIST, HIP, KNEE, AND ANKLE)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Pain, weakness, stiffness, swelling, heat and redness, instability
or giving way,

\"locking,\" fatigability, lack of endurance, etc.

2\. Treatment - type, dose, frequency, response, side effects.

3\. If there are periods of flare-up of joint disease:

a\. State their severity, frequency, and duration.

b\. Name the precipitating and alleviating factors.

c\. Estimate to what extent, if any, they result in additional
limitation of motion or

functional impairment during the flare-up.

4\. Describe whether crutches, brace, cane, corrective shoes, etc., are
needed.

5\. Describe details of any surgery or injury.

6\. Describe any episodes of dislocation or recurrent subluxation.

7\. For inflammatory arthritis, describe any constitutional symptoms.

8\. Describe the effects of the condition on the veteran\'s usual
occupation and daily

activities.

9\. Dominance of extremity and means used to identify dominant
extremity.

10\. If there is a prosthesis, provide date of prosthetic implant and
describe any complaint

of pain, weakness, or limitation of motion. State whether crutches,
brace, etc., are

needed.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the condition being
examined and fully

describe current findings: [A detailed assessment of each affected joint
is required,]{.underline}

[including joints with prostheses]{.underline}.

1\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance. Provide range of
motion in

degrees.

2\. If the joint is painful on motion, state at what point in the range
of motion pain begins

and ends.

3\. State to what extent (if any) and in which degrees (if possible) the
range of motion or

joint function is [additionally limited]{.underline} by pain, fatigue,
weakness, or lack of endurance

following repetitive use or during flare-ups. If more than one of these
is present, state,

if possible, which has the major functional impact.

4\. Describe objective evidence of painful motion, edema, effusion,
instability, weakness,

tenderness, redness, heat, abnormal movement, guarding of movement, etc.

5\. For weight bearing joints (hip, knee, ankle), describe gait and
functional limitations on

standing and walking. Describe any callosities, breakdown, or unusual
shoe wear

pattern that would indicate abnormal weight bearing.

6\. If ankylosis is present, describe the position of the bones of the
joint in relationship to

one another (in degrees of flexion, external rotation, etc.), and state
whether the

ankylosis is stable and pain free.

7\. If indicated, measure the leg length from the anterior superior
iliac spine to the medial

malleolus.

8\. For [inflammatory arthritis]{.underline}, describe any
constitutional signs.

9\. Describe range of motion with prosthesis in same detail as described
above for

nonprosthetic joints.

D. **Normal Range of Motion:** All joint Range of Motion measurements
must be made using a **[goniometer]{.underline}**. Show each measured
range of motion separately rather than as a continuum. For example, if
the veteran lacks 10 degrees of full knee extension and has normal
flexion, show the range of motion as extension to minus 10 degrees (or
lacks 10 degrees of extension) and flexion

0 to 140 degrees.

1\. [Hip range of motion:]{.underline} (Movement of femur as it rotates
in the acetabulum.)

a\. Normal range of motion, using the anatomical position as zero
degrees.

[Flexion]{.underline} = 0 to 125 degrees (To gain a true picture of hip
flexion, i.e.,

movement between the pelvis and femur in the hip joint, the opposite
thigh

should be extended to minimize motion between the pelvis and spine.)

[Extension]{.underline} = 0 to 30 degrees.

[Adduction]{.underline} = 0 to 25 degrees.

[Abduction]{.underline} = 0 to 45 degrees.

[External rotation]{.underline} = 0 to 60 degrees.

[Internal rotation]{.underline} = 0 to 40 degrees.

2\. [Knee range of motion:]{.underline}

a\. Normal range of motion, using the anatomical position as zero
degrees.

[Flexion]{.underline} = 0 to 140 degrees.

[Extension]{.underline} - zero degrees = full extension. Show loss of
extension by describing

the degrees in which extension is not possible. (e.g., Show range of
motion as

extension to minus 10 degrees and flexion 0 to 140 degrees when full
extension

is limited by 10 degrees and full flexion is possible.)

b\. Stability.

[Medial and Lateral Collateral Ligaments:]{.underline}
[Varus/valgus]{.underline} in neutral and in 30

degrees of flexion - normal is no motion.

[Anterior and Posterior Cruciate Ligaments:]{.underline}
[Anterior/posterior]{.underline} in 30 degrees of

flexion with foot stabilized - normal is less than 5 mm. of motion (1/4
inch -

Lachman\'s test) or in 90 degrees of flexion with foot stabilized -
normal is less

than 5mm. of motion (1/4 inch - anterior and posterior drawer test).

[Medial and Lateral Meniscus:]{.underline} Perform McMurray\'s test.

3\. [Ankle range of motion:]{.underline}

a\. Neutral position is with foot at 90 degrees to ankle. From that
position,

dorsiflexion is 0 to 20 degrees; plantar flexion is 0 to 45 degrees.

b\. Describe any varus or valgus angulation of the os calcis in
relationship to the

long axis of the tibia and fibula.

4\. [Shoulder, elbow, forearm, and wrist range of motion:]{.underline}

a\. Normal range of motion is measured with zero degrees the anatomical
position

[except]{.underline} for 2 situations:

\(1\) Supination and pronation of the forearm is measured with the arm

against the body, the elbow flexed to 90 degrees, and the forearm in

mid position (zero degrees) between supination and pronation.

\(2\) Shoulder rotation is measured with the arm abducted to 90 degrees,

the elbow flexed to 90 degrees, and the forearm reflecting the midpoint

(zero degrees) between internal and external rotation of the shoulder.

b\. [Shoulder forward flexion]{.underline} = zero to 180 degrees.

c\. [Shoulder abduction]{.underline} = zero to 180 degrees.

d\. [Shoulder external rotation]{.underline} = zero to 90 degrees.

e\. [Shoulder internal rotation]{.underline} = zero to 90 degrees.

f\. [Elbow flexion]{.underline} = zero to 145 degrees.

g\. [Forearm supination]{.underline} = zero to 85 degrees.

h\. [Forearm pronation]{.underline} = zero to 80 degrees.

i\. [Wrist dorsiflexion]{.underline} (extension) = zero to 70 degrees.

j\. [Wrist palmar flexion]{.underline} = zero to 80 degrees.

k\. [Wrist radial deviation]{.underline} = zero to 20 degrees.

l\. [Wrist ulnar deviation]{.underline} = zero to 45 degrees.

E. **Diagnostic and Clinical Tests:**

1\. As indicated: X-rays, including special views or weight bearing
films, MRI,

arthrogram, diagnostic arthroscopy.

**Note:** The diagnosis of degenerative arthritis or post-traumatic
arthritis of a joint requires

2\. Include results of all diagnostic and clinical tests in the
examination report.

X-ray confirmation. Once the diagnosis has been confirmed in a joint,
further X-rays of

that joint are not required.

F. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**HAND, THUMB, AND FINGERS**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. If there are periods of flare-up of joint disease:

a\. State their severity, frequency, and duration.

b\. Name the precipitating and alleviating factors.

c\. Estimate to what extent, if any, they result in additional
limitation of motion or

functional impairment during the flare-up.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the condition being
examined and fully

describe current findings:

1\. Anatomical defects.

2\. Functional defects (motion of thumb and fingers should be described
as to how near, in

inches, the tip of thumb can approximate the fingers, or how near the
tips of fingers can

approximate the median transverse fold of the palm.

3\. Grasping objects (strength and dexterity).

The hand should be evaluated as a unit intricately adapted for grasping,
pushing, pulling, twisting, probing, writing, touching, and expression.
Do not designate fingers numerically; use thumb, index, middle (or
long), ring, and little. Specify which hand is involved and state
whether the individual is right- or left-handed. Designate the joints as
wrist, MP (metacarpophalangeal), PIP (proximal interphalangeal), or DIP
(distal interphalangeal). Designate phalanges as proximal, middle or
distal.

4\. [A detailed assessment of each affected joint is
required]{.underline}.

a\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance.

b\. State to what extent (if any) and in which degrees (if possible) the
range of

motion or joint function is [additionally limited]{.underline} by pain,
fatigue, weakness, or

lack of endurance following repetitive use or during flare-ups. If more
than one

of these is present, state, if possible, which has the major functional
impact.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**FEET**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Pain, weakness, stiffness, swelling, heat, redness, fatigability,
lack of endurance, etc.

Describe symptoms at rest and on standing and walking.

2\. Treatment - type, dose, frequency, response, side effects.

3\. If there are periods of flare-up of joint disease:

a\. State their severity, frequency, and duration.

b\. Name the precipitating and alleviating factors.

c\. Estimate to what extent, if any, they result in additional
limitation of motion or

functional impairment during the flare-up.

4\. Describe whether crutches, brace, cane, corrective shoes, etc., are
needed.

5\. Describe details of any surgery or injury.

6\. Describe corrective shoes, shoe inserts, or braces used and their
efficacy.

7\. Describe effects of the condition(s) on the veteran\'s usual
occupation and daily

activities.

C. **Physical Examination (Objective Findings)**

Address each of the following as appropriate to the condition being
examined and fully describe current findings: [A detailed assessment of
each affected joint is required]{.underline}.

1\. Describe each foot separately. For nomenclature of toes use: great
toe, second, third,

fourth, and fifth. The functional loss should be related to the
anatomical condition.

2\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance.

3\. If the joint is painful on motion, state at what point in the range
of motion pain begins

and ends.

4\. State to what extent (if any) and in which degrees (if possible) the
range of motion or

function is [additionally limited]{.underline} by pain, fatigue,
weakness, or lack of endurance

following repetitive use or during flare-ups. If more than one of these
is present, state,

if possible, which has the major functional impact.

5\. Describe objective evidence of painful motion, edema, instability,
weakness,

tenderness, etc.

6\. Describe gait and functional limitations on standing and walking.

7\. Describe any callosities, breakdown, or unusual shoe wear pattern
that would indicate

abnormal weight bearing.

8\. Describe any skin and vascular changes.

9\. Posture on standing, squatting, supination, pronation, and rising on
toes and heels.

10\. Describe hammertoes, high arch, clawfoot, or other deformity -
actively or passively

correctable?

11\. For flatfoot

a\. Describe weight bearing and non-weight bearing alignment of the
Achilles

tendon.

b\. Describe whether the Achilles tendon alignment can be corrected by

manipulation and whether there is pain on manipulation.

c\. Describe degrees of valgus and whether correctable by manipulation.

d\. Describe extent of forefoot and midfoot malalignment and whether
correctable

by manipulation.

12\. For hallux valgus, describe angulation and dorsiflexion at first
metatarso-phalangeal

joints.

D. **Diagnostic and Clinical Tests:**

Comment on:

1\. X-rays for flatfoot and clawfoot - weight bearing AP and lateral
views and non-weight

bearing AP, lateral, and oblique views.

2\. For other conditions, AP lateral and oblique of entire foot as
applicable.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**SPINE (CERVICAL, THORACIC, AND LUMBAR)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Present Medical History (Subjective Complaints):**

Comment on:

1\. Complaints of pain, weakness, stiffness, fatigability, lack of
endurance, etc.

2\. Treatment - type, dose, frequency, response, side effects

3\. If there are periods of flare-up:

a\. State their severity, frequency, and duration.

b\. Name the precipitating and alleviating factors.

c\. Estimate to what extent, if any, they result in additional
limitation of motion or

functional impairment during the flare-up.

4\. Describe whether crutches, brace, cane, etc., are needed.

5\. Describe details of any surgery or injury.

6\. Functional Assessment - Describe effects of the condition(s) on the
veteran\'s usual

occupation and daily activities.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the condition being
examined and fully

describe current findings:

1\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance. Provide range of
motion in

degrees.

2\. If the spine is painful on motion, state at what point in the range
of motion pain begins

and ends.

3\. State to what extent (if any) and in which degrees (if possible) the
range of motion or

spinal function is [additionally limited]{.underline} by pain, fatigue,
weakness, or lack of endurance

following repetitive use or during flare-ups. If more than one of these
is present, state,

if possible, which has the major functional impact.

4\. Describe objective evidence of painful motion, spasm, weakness,
tenderness, etc.

5\. Postural abnormalities, fixed deformity.

6\. Musculature of back.

7\. Neurological abnormalities - if present, see appropriate worksheet.

D. **Normal Range of Motion:** All joint Range of Motion measurements
must be made using a **[goniometer]{.underline}**. Show each measured
range of motion separately rather than as a continuum.

E. **Diagnostic and Clinical Tests:**

Obtain the following and comment on them, as indicated:

1\. X-rays, MRI, as indicated.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

F. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**MUSCLES**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. If there are periods of flare-up of residuals of muscle injury:

a\. State their severity, frequency, and duration.

b\. Name the precipitating and alleviating factors.

c\. Estimate to what extent, if any, they result in additional
limitation of motion or

functional impairment during the flare-up.

2\. If injury is due to a missile: initial treatment in the field,
length of initial hospitalization

and any surgeries or other repairs undertaken, time for return to duty
or limited duty or

determination that duty could not be resumed.

3\. Record exact muscles injured or destroyed and describe.

4\. Record any associated injuries, particularly those affecting bony
structures, nerves or

vascular structures and specify the nature of treatment required.

5\. Describe present symptoms of muscle pain, activity limited by
fatigue or inability to

move joint through a portion of its range; and the degree to which this
interferes with

activities of daily living.

6\. For tumors of muscle, describe onset of symptoms, date(s) of biopsy
and/or surgical

excision and residual defects. If malignant neoplasm, need date of
diagnosis, dates and

type of treatment, and date of last treatment.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Entry and exit wound scars as well as dimensions.

2\. Tissue loss comparison, and specify muscle group(s) penetrated.

3\. Scar formation measurement (sensitivity, tenderness, etc.)

4\. Adhesions.

5\. Tendon damage.

6\. Bone, joint or nerve damage.

7\. Muscle strength.

8\. Muscle herniation and, if any, if supported by a truss or belt.

9\. Loss of muscle function. Can muscle group move joint through normal
range with

sufficient comfort, endurance and strength to accomplish activities of
daily living? Can

muscle group move joint independently through useful ranges of motion
but with

limitation by pain or easy fatigability or weakness? Can muscle group
move joint only

with assistance or with gravity eliminated? Is there no ability of
muscle group to move

joint even with gravity eliminated and joint passively moveable? Is any
muscle

contraction felt?

10\. If joint function is affected:

a\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance

b\. State to what extent (if any) and in which degrees (if possible) the
range of

motion or function is [additionally limited]{.underline} by pain,
fatigue, weakness, or lack of

endurance following repetitive use or during flare-ups. If more than one
of

these is present, state, if possible, which has the major functional
impact.

D. **Diagnostic and Clinical Tests:**

1\. If applicable, x-rays of joint(s) involved in two planes or anatomic
area involved if not

recorded in past (once taken, the x-rays do not need to be repeated).

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**EYE EXAMINATION**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Pain.

2\. Duration and frequency of periods of incapacitation, and rest
requirements.

3\. Visual symptoms, including distorted or enlarged image, etc.

4\. Current ophthalmologic treatment.

5\. For malignant neoplasms, state type of treatment and last date. If
treatment is current,

describe.

C. **Physical Examination (Objective Findings):**

Address each of the following, **[as applicable]{.underline}**, and
[fully describe current findings]{.underline}:

1\. Visual Acuity:

a\. Examine each eye independently and record the refractive information
indicated

below.

b\. Use conventional lenses for correction unless the patient has
keratoconus, is

well adapted to contact lenses and wishes to wear them, and contact
lenses

result in best corrected visual acuity. In that case, use contact lenses
to

determine best corrected visual acuity.

c\. Use Snellen\'s test type or its equivalent.

d\. Carry out an examination with the pupils dilated unless
contraindicated, and

record the ophthalmic findings.

e\. For visual acuity worse than 5/200 in either or both eyes, report
the distance in

feet/inches (or meters/centimeters) from the face at which the veteran
can count

fingers/detect hand motion/read the largest line on the chart. If the
veteran

cannot detect hand motion or count fingers at any distance, state
whether

he or she has light perception.

f\. If keratoconus is present, state whether contact lenses are required
or adequate

correction is possible by other means.

**NEAR FAR**

Right Eye Uncorrected \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_

RIGHT EYE CORRECTED \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_

**NEAR FAR**

LEFT EYE Uncorrected \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_

LEFT EYE CORRECTED \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_

2\. Diplopia:

a\. Perform the measurement of muscle function using a Goldmann
Perimeter

Chart and chart the areas in which diplopia exists. Include the chart as
part of

the examination report to be sent to the regional office.

b\. If diplopia is present, state whether it is constant or
intermittent, whether it is

present at all distances or only for near or distant vision, and whether
it is

correctable by use of lenses or prisms.

c\. If diplopia is constant and not correctable, indicate which sectors
of the visual

field are affected and provide the Goldmann perimeter chart showing the
actual

areas of diplopia, according to the format below. Diplopia outside these
areas

should also be reported even though it is not considered disabling
because it

may be used in the evaluation of the underlying disease or injury.

[CENTRAL 20 DEGREES]{.underline} \_\_\_\_\_\_\_\_\_

[21 TO 30 DEGREES]{.underline}

[DOWN]{.underline}

RIGHT LATERAL \_\_\_\_\_\_\_\_

LEFT LATERAL \_\_\_\_\_\_\_\_

[UP]{.underline}

RIGHT LATERAL \_\_\_\_\_\_\_\_

LEFT LATERAL \_\_\_\_\_\_\_\_

[31 TO 40 DEGREES]{.underline}

[DOWN]{.underline}

RIGHT LATERAL \_\_\_\_\_\_\_\_

LEFT LATERAL \_\_\_\_\_\_\_\_

[UP]{.underline}

RIGHT LATERAL \_\_\_\_\_\_\_\_

LEFT LATERAL \_\_\_\_\_\_\_\_

3\. Visual Field Deficit:

a\. Chart any visual field defect using a Goldmann Perimeter Chart and
include the

chart as part of the examination report to be sent to the regional
office.

b\. For an aphakic eye which cannot be fitted with contact lenses or
intra-ocular

implant, use the IV/4e test object. For all other cases, use the III/4e
test object.

c\. If the examiner determines that charting with other test objects is
indicated,

those test results should be reported on a separate chart. All charts,
along with

an explanation of the need for using a different test object and an
explanation of

any discrepancies in results, should be included as part of the
examination

report.

d\. All scotomas should be plotted carefully in order to allow
measurements to be

made for adjustments in the calculation of visual field defects.

4\. Details of eye disease or injury (including eyebrows, eyelashes,
eyelids) other than loss

of visual acuity, diplopia, or visual field defect:

D. **Diagnostic and Clinical Tests:** (Other than for visual acuity,
diplopia, and visual fields, as

described above.)

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis**:

Signature: Date:

Compensation and Pension Examination

**AUDIO**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

[Narrative:]{.underline} An examination of hearing impairment must be
conducted by a state-licensed audiologist and must include a controlled
speech discrimination test (specifically, the Maryland CNC *recording*)
and a pure tone audiometry test in a sound isolated booth that meets
American National Standards Institute standards (ANSI S3.1. 1991) for
ambient noise. Measurements will be reported at the frequencies of 500,
1000, 2000, 3000, and 4000 Hz. The examination will include the
following tests: Pure tone audiometry by air conduction at 250, 500,
1000, 2000, 3000, 4000, and 8000 Hz, and by bone conduction at 250, 500,
1000, 2000, 3000, and 4000 Hz, spondee thresholds, speech recognition
using the recorded Maryland CNC Test, tympanometry and acoustic reflex
tests, and, when necessary, Stenger tests. Bone conduction thresholds
are measured when the air conduction thresholds are poorer than 15 dB
HL. A modified Hughson-Westlake procedure will be used with appropriate
masking. A Stenger must be administered whenever pure tone air
conduction thresholds at 500, 1000, 2000, 3000, and 4000 Hz differ by 20
dB or more between the two ears. Maximum speech recognition will be
reported with the 50 word VA approved recording of the Maryland CNC
test. When speech recognition is 92% or less, a performance intensity
function will be obtained with a starting presentation level 40 dB re
SRT. If necessary, the starting level will be adjusted upward to obtain
a level at least 5 dB above the threshold at 2000 Hz. The examination
will be conducted without the use of hearing aids. Both ears must be
examined for hearing impairment even if hearing loss in only one ear is
at issue.

A. **Review of Medical Records:** Indicate whether the C-file was
reviewed.

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Chief complaint.

2\. Situation of greatest difficulty.

3\. Pertinent service history.

4\. History of military, occupational, and recreational noise exposure.

5\. Tinnitus - If present, state:

a\. Date and circumstances of onset.

b\. Whether it is unilateral or bilateral.

c.  Whether it is recurrent (indicate frequency and duration).

d.  The most likely etiology of the tinnitus, and specifically, if
    hearing loss is present, whether the tinnitus is due to the same
    etiology (or causative factor) as the hearing loss.

C. **Physical Examination (Objective Findings):**

1\. Measure puretone thresholds in decibels at the indicated frequencies
(air conduction):

= = = = = = =RIGHT EAR= = = = = = = = = = = = = = = = = LEFT EAR = = = =
= = =

A\* B C D E \*\* A\* B C D E \*\*

500 \| 1000 \| 2000 \| 3000 \| 4000 \| average 500 \| 1000 \| 2000 \|
3000 \| 4000 \| average

\* The puretone threshold at 500 Hz is not used in determining the
evaluation but is used in

determining whether or not a ratable hearing loss exists.

\*\* The average of B, C, D, and E.

2.  Speech Recognition Score: Maryland CNC word list

> \_\_\_\_\_\_\_% right ear \_\_\_\_\_\_% left ear.

3.  When only puretone results should be used to evaluate hearing loss,
    the examiner, who must be a state-licensed audiologist, should
    certify that language difficulties or other problems (specify what
    the problems are) make the combined use of puretone average and
    speech discrimination inappropriate.

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D.  **Diagnostic and Clinical Tests:**

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1.  Report middle ear status, confirm type of loss, and indicate need
    for medical follow-up. In cases where there is poor inter-test
    reliability and/or positive Stenger test results, obtain and report
    estimates of hearing thresholds using a combination of behavioral
    testing, Stenger interference levels, and electrophysiological
    tests.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

> 1\. Summary of audiologic test results. Indicate type and degree of
> hearing loss for the frequency range from 500 to 4000 Hz. For type of
> loss, indicate whether it is normal, conductive, sensorineural,
> central, or mixed. For degree, indicate whether it is mild (26-40 HL),
> moderate (41-54 HL), moderately severe (55-69HL), severe (70-89 HL),
> or profound (90+HL).
>
> \[For VA purposes, impaired hearing is considered to be a disability
> when the auditory threshold in any of the frequencies 500, 1000, 2000,
> 3000, and 4000 Hz is 40 dB HL or greater; or when the auditory
> thresholds for at least three of these frequencies are 26 dB HL or
> greater; or when speech recognition scores are less than 94%.\]
>
> 2\. Note whether, based on audiologic results, medical follow-up is
> needed for an ear or hearing problem, and whether there is a problem
> which, if treated, might cause a change in hearing threshold levels.

Signature: Date:

Compensation and Pension Examination

**EAR DISEASE**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:** Indicate whether the C-file was
reviewed.

B. **Medical History (Subjective Complaints):**

> 1\. Describe history of hearing loss, tinnitus, vertigo, balance or
> gait problems, discharge, pain, pruritus. State onset and frequency
> and duration of each, if not constant.
>
> 2\. Describe current or past treatment for ear conditions.
>
> 3\. If a malignant neoplasm of the ear is or was present:
>
> a\. State date of confirmed diagnosis.

b.  State date of the last surgical, X-ray, antineoplastic chemotherapy,
    radiation, or other therapeutic procedure.

c.  State expected date treatment regimen is to be completed.

d.  If treatment is already completed, provide date of last treatment.

e.  If treatment is already completed, fully describe residuals.

C. **Physical Examination (Objective Findings):**

> 1\. Conduct an external and otoscopic examination. Address each of the
> following and describe current findings, including abnormalities of
> size, shape, or form:

a.  Auricle. Any deformity? If there is tissue loss, state whether it is
    one-third or more of auricle.

b.  External canal - describe any edema, scaling, discharge.

c.  Tympanic membrane.

d.  The tympanum.

e.  Mastoids. Discharge? Evidence of cholesteatoma?

f.  State all conditions secondary to ear disease, such as disturbance
    of balance, upper respiratory disease, hearing loss, etc.

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2.  State whether an active ear disease is present.

3.  Infections of the middle or inner ear. Is there suppuration?
    Effusion? Are aural polyps present?

4.  For peripheral vestibular disorders, state the specific diagnosis
    and its basis, whether there is dizziness and how often, and whether
    a staggering gait occurs and how often.

5.  For Meniere's syndrome, state the symptoms, including the frequency
    of attacks of vertigo and cerebellar gait. Is tinnitus present? If
    so, how frequently and what is its duration? Is there hearing loss?
    (See audio worksheet.)

> 6\. Describe any complications of ear disease that are present.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**SENSE OF SMELL AND TASTE**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

C. **Physical Examination (Objective Findings):**

D. **Diagnostic and Clinical Tests:**

1\. For [sense of smell]{.underline}, test each side of nose separately.
State results with the following

substances recommended for testing:

a\. Coffee.

b\. Soap.

c\. Oil of lemon.

d\. Other (state substance).

2\. For [sense of taste]{.underline}

a\. Using electrogustometry if available, test for:

\(1\) Sweet.

\(2\) Sour.

\(3\) Bitter.

\(4\) Salt.

b\. State results with the following substances recommended for testing:

\(1\) Sugar.

\(2\) Diluted acetic acid.

\(3\) Lemon or Orange.

\(4\) Salt.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Provide:

1\. State whether loss of sense of smell is partial or complete, and its
basis.

2\. State whether loss of sense of taste is partial or complete, and its
basis.

3\. If a psychiatric basis is suspected, a special psychiatric
examination should be ordered.

Signature: Date:

Compensation and Pension Examination

**INFECTIOUS, IMMUNE, AND NUTRITIONAL DISABILITIES**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

Narrative: Many infectious diseases, immune disorders, and nutritional
deficiencies have acute phases at onset and accompanying recurrences but
leave little or no residual disability beyond the acute phase. Other
such conditions may have slow progression and show significant residual
disability. The examiner must diligently search for residual
disabilities upon which adjudication of the case may be made.

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Date of symptom onset.

2\. Date of diagnosis.

3\. Clinical manifestations.

4\. Treatment (type, frequency, duration, response, side effects).

5\. Disease activity (exacerbations and/or remissions)? If there were
exacerbations,

what was the state of the veteran\'s health between exacerbations?
Frequency and

duration of exacerbations.

6\. Current symptoms

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Is the condition still present?

2\. Current weight, nutrition. Any residuals of malnutrition, vitamin
deficiency?

3\. General appearance.

4\. Describe findings of all organ systems involved. See appropriate
examination

worksheets - respiratory, joints, cardiovascular, etc.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

**Note:** If an infectious etiology is documented, specify the organism.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**HIV-RELATED ILLNESS**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment On:

1\. Recurrent opportunistic infections.

2\. Recurrent constitutional symptoms.

3\. Diarrhea.

4\. Debility.

5\. Progressive weight loss.

6\. Remissions in any symptomatology.

7\. Depression or memory loss.

8\. Treatment - Is this an approved medication?

9\. Describe the effects of the condition on the veteran\'s usual
occupation and daily

activities.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe:

1\. Definitive diagnosis of AIDS. (Use CDC Definition.)

2\. Secondary diseases affecting multiple body systems - describe.

3\. HIV-related illnesses - describe.

4\. Neoplasm related to HIV-related illness. Describe.

5\. T4 cell counts.

6\. Hairy cell leukoplakia.

7\. Oral candidiasis.

8\. Use of HIV-related medications.

9\. Lymphadenopathy.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. T4 Cell counts.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

# **CHRONIC FATIGUE SYNDROME**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

Narrative: Chronic fatigue syndrome (CFS) is an illness characterized by
debilitating fatigue and several flu-like symptoms. It may have both
physical and psychiatric manifestations and closely resembles
neurasthenia, neurocirculatory asthenia, fibrositis, or fibromyalgia.

**For VA purposes, a diagnosis of CFS must meet both of the following
criteria:**

1\. New onset of debilitating fatigue that is severe enough to reduce or
impair average

daily activity below 50 percent of the patient\'s pre-illness activity
level for a period

of 6 months, and

2\. Other clinical conditions that may produce similar symptoms must be
excluded

by thorough evaluation, based on history, physical examination, and
appropriate

laboratory tests.

**It must also meet six or more of the following ten criteria:**

1\. Describe in detail:

a\. Acute onset of the condition.

b\. Low grade fever.

c\. Nonexudative pharyngitis.

d\. Palpable or tender cervical or axillary lymph nodes.

e\. Generalized muscle aches or weakness.

f\. Fatigue following lasting 24 hours or longer after exercise.

g\. Headaches (of a type, severity or pattern that is different from
headaches in the

premorbid state.

h\. Migratory joint pains.

i\. Neuropsychologic symptoms.

j\. Sleep disturbance.

A. **Review of Medical Records:**

Comment on:

1\. Date diagnosis established.

2\. Does it meet the requirements outlined above?

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Estimate the amount of routine daily activities that are restricted
due to CFS. Give

specific examples.

2\. If there are incapacitating episodes (requiring bed rest and
treatment by a physician),

what is their frequency and duration?.

3\. Does the patient require continuous medication for CFS?

C. **Physical Examination (Objective Findings):**

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**NOSE, SINUS, LARYNX, AND PHARYNX**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Location and nature of the injury or disease.

2\. Interference with breathing through nose.

3\. Purulent discharge.

4\. Dyspnea at rest or on exertion?

5\. Treatments - type (surgery, medication, oxygen, respirator, etc.)
frequency, duration,

response, and side effects.

respirators, etc., response, and side effects.

6\. If speech impairment (ability to communicate by speech, ability to
speak above a

whisper, etc.).

7\. For chronic sinusitis, indicate which sinuses are affected and
whether pain and

headaches are present. Describe severity and frequency.

8\. If allergic attacks, frequency and baseline status between attacks.

9\. Other symptoms noted.

10\. Describe frequency and duration of periods of incapacitation
(defined as requiring

bedrest and treatment by a physician).

C. **Physical Examination (Objective Findings):**

Provide:

1\. If there is nasal obstruction, indicate percent each nostril.

2\. Sinusitis - Describe tenderness, purulent discharge, or crusting.

D. **Diagnostic and Clinical Tests:**

1\. If there is stenosis of larynx, order [FEV-1 with flow-volume
loop]{.underline}.

2\. If there is facial disfigurement, order [color
photographs]{.underline}.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Comment on whether the disease primarily involves or originates from the
nose, sinus,

larynx, or pharynx.

Signature: Date:

Compensation and Pension Examination

**RESPIRATORY (OBSTRUCTIVE, RESTRICTIVE, AND INTERSTITIAL)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Productive cough, sputum, hemoptysis, and/or anorexia.

2\. Extent of dyspnea on exertion.

3\. If veteran is asthmatic, report frequency of attacks and baseline
functional status

between attacks.

4\. Treatment (type, frequency and duration including a need for
oxygen), response, side

effects.

5\. Describe frequency and duration of any periods of incapacitation
(defined as requiring

bedrest and treatment by a physician).

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the condition being
examined and fully

describe current findings:

1\. Presence of cor pulmonale, RVH or pulmonary hypertension.

2\. Weight loss or gain.

3\. For restrictive disease, describe condition underlying restrictive
disease,

e.g., kyphoscoliosis, pectus excavatum, etc., unless already of record.

D. **Diagnostic and Clinical Tests:**

Provide:

1.  [Pulmonary Function Tests]{.underline} (unless carried out within
    past six months and the report is either in the claims folder or
    will be attached to this examination report, e.g., PFT\'s were in
    VAMC records at your facility). Spirometric pulmonary function
    testing should include FVC, FEV-1, and the FEV-1/FVC ratio. Both
    pre- and post-bronchodilatation test results should be reported. If
    post-bronchodilatation testing is not conducted in a particular
    case, please provide an explanation of why not. A DLCO may or may
    not be done routinely as part of pulmonary function testing at a
    particular facility. If there is a disparity between the results of
    different tests, please indicate which tests are more likely to
    accurately reflect the severity of the condition.

> **DLCO note**: If the DLCO was not done as a routine part of pulmonary
> function testing, the examiner should use his or her judgment, based
> on the specific condition (e.g., whether it is obstructive,
> interstitial, etc.) and other available information about the
> condition, as to whether a DLCO test is needed, since it is not useful
> in all situations. If it may provide useful information about the
> severity of the condition, it should be requested and reviewed before
> the examination report is submitted. If the examiner determines that
> the DLCO test is not needed, a statement as to why not (e.g., there
> are decreased lung volumes that would not yield valid test results)
> should be included in the report. Such a statement could avoid a
> remand from BVA when the test is not done. However, in the case of a
> BVA remand in which the DLCO is requested, the DLCO MUST be done
> unless there is a medical contraindication.

2.  Chest X-ray (if no recent results available).

3.  Include results of all diagnostic and clinical tests conducted in
    the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**PULMONARY TUBERCULOSIS AND MYCOBACTERIAL DISEASES**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Activity of pulmonary tuberculosis or other mycobacterial disease.

2\. Date of inactivity if it is not active.

3\. Identity of organism (if possible).

C. **Physical examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Extent of structural damage to lungs.

2\. If patient was hospitalized for 6 months or more, what is the
condition at the end of

hospitalization?

3\. If patient was hospitalized for 12 months or more, what is the
condition at the end of

hospitalization?

D. **Diagnostic and Clinical Tests:**

Provide:

1.  Pulmonary Function Tests, if indicated. If performed, include the
    results in the examination report. The FEV-1, FVC, and FEV-1/FVC
    should be included. Both pre- and post-bronchodilatation pulmonary
    function test results should be reported. If post-bronchodilatation
    testing is not conducted in a particular case, please provide an
    explanation of why not. A DLCO may or may not be done routinely as
    part of pulmonary function testing at a particular facility. If
    there is a disparity between the results of different tests, please
    indicate which tests are more likely to accurately reflect the
    severity of the condition.

> **DLCO note**: If the DLCO was not done as a routine part of pulmonary
> function testing, the examiner should use his or her judgment, based
> on the specific condition (e.g., whether it is obstructive,
> interstitial, etc.) and other available information about the
> condition, as to whether a DLCO test is needed, since it is not useful
> in all situations. If it may provide useful information about the
> severity of the condition, it should be requested and reviewed before
> the examination report is submitted. If the examiner determines that
> the DLCO test is not needed, a statement as to why not (e.g., there
> are decreased lung volumes that would not yield valid test results)
> should be included in the report. Such a statement could avoid a
> remand from BVA when the test is not done. However, in the case of a
> BVA remand in which the DLCO is requested, the DLCO MUST be done
> unless there is a medical contraindication.

E. **Diagnosis:**

1.  In reactivated cases, is this reactivation of the old disease or a
    separate and distinct new infection?

[Additional note to the examiner:]{.underline}

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.

Signature: Date:

Compensation and Pension Examination

**RESPIRATORY DISEASES, MISCELLANEOUS**

**(PVD, Neoplasms, Bacterial Infections,**

**Mycotic Lung Disease, Sarcoidosis, and Sleep Apnea)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Fever and/or night sweats.

2\. Weight loss or gain.

3\. Daytime hypersomnolence.

4\. Hemoptysis.

5\. Describe current treatment such as anticoagulant, tracheostomy,
CPAP, oxygen, or

antimicrobial therapy.

6\. If malignant disease, state initial treatment date, site of original
tumor, type of tumor,

types of treatment used, and date treatment is expected to end. If
treatment has been

completed, state date treatment was completed.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the condition being
examined and fully

describe current findings:

1\. Pulmonary Hypertension, RVH, cor pulmonale, or congestive heart
failure.

2\. Residuals of pulmonary embolism.

3\. Respiratory Failure.

4\. Evidence of chronic pulmonary thromboembolism.

5\. If ankylosing spondylitis, is there restriction of the chest
excursion and dyspnea on

minimal exertion?

6\. Describe all residuals of malignancy including those due to
treatment.

D. **Diagnostic and Clinical Tests:**

1.  Pulmonary Function Tests, if indicated. The FEV-1, FVC, and
    FEV-1/FVC should be included. Both pre- and post-bronchodilatation
    pulmonary function test results should be reported. If
    post-bronchodilatation testing is not conducted in a particular
    case, please provide an explanation of why not. A DLCO may or may
    not be done routinely as part of pulmonary function testing at a
    particular facility. If there is a disparity between the results of
    different tests, please indicate which tests are more likely to
    accurately reflect the severity of the condition.

> **DLCO note**: If the DLCO was not done as a routine part of pulmonary
> function testing, the examiner should use his or her judgment, based
> on the specific condition (e.g., whether it is obstructive,
> interstitial, etc.) and other available information about the
> condition, as to whether a DLCO test is needed. If it may provide
> useful information about the severity of the condition, it should be
> requested and reviewed before the examination report is submitted. If
> the examiner determines that the DLCO test is not needed, a statement
> as to why not (e.g., there are decreased lung volumes that would not
> yield valid test results) should be included in the report. Such a
> statement could avoid a remand from BVA when the test is not done.
> However, in the case of a BVA remand in which the DLCO is requested,
> the DLCO MUST be done unless there is a medical contraindication.

2\. If sleep apnea is suspected, order [Sleep Studies]{.underline}.

3\. Chest X-ray if necessary to document sarcoidosis or other
parenchymal disease.

4\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**HEART**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1.  Past history - describe onset of disorder and frequency of cardiac
    symptoms, including angina, dyspnea, fatigue, dizziness, and
    syncope. Record dates and severity of episodes of acute cardiac
    illness, including myocardial infarction, congestive heart failure,
    and acute rheumatic heart disease. Describe all cardiac surgery,
    including coronary artery bypass, valvular surgery, cardiac
    transplant, and angioplasty.

2.  Current treatment - type, dosage, response, and side effects.

3.  With the exceptions given below, examinations for valvular heart
    disease, endocarditis, pericarditis, pericardial adhesions,
    syphilitic heart disease,, arteriosclerotic heart disease,
    myocardial infarction, hypertensive heart disease, heart valve
    replacement, coronary bypass surgery, cardiac transplantation, and
    cardiomyopathy, require the examiner [to provide the METs level,
    determined by exercise testing]{.underline}, at which symptoms of
    dyspnea, fatigue, angina, dizziness, or syncope result.

4.  Exercise testing is [not]{.underline} required for the above listed
    conditions in the following circumstances:

> a\. If exercise testing is medically contraindicated:

1.  In that case, provide the medical reason exercise testing cannot be
    conducted, and

2.  [Provide an estimate of the level of activity (expressed in METs and
    supported by specific examples]{.underline}, such as slow stair
    climbing, or shoveling snow) that results in dyspnea, fatigue,
    angina, dizziness, or syncope.

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b.  If left ventricular dysfunction is present, and the ejection
    fraction is 50 percent or less.

c.  If there is chronic congestive heart failure or there has been more
    than one episode of acute congestive heart failure in the past year.

d.  With valvular heart disease---during active infection with valvular
    heart damage and for three months following cessation of therapy for
    the active infection.

e.  With endocarditis---for three months following cessation of therapy
    for active infection with cardiac involvement.

f.  With pericarditis---for three months following cessation of therapy
    for active infection with cardiac involvement.

g.  With myocardial infarction---for three months following myocardial
    infarction.

h.  With valve replacement---for six months following date of hospital
    admission for valve replacement.

i.  With coronary bypass surgery---for three months following hospital
    admission for surgery.

j.  For cardiac transplantation---for indefinite period from date of
    hospital admission for cardiac transplantation.

k.  If an exercise test has been done within the past year, the results
    are of record, and there is no indication that there has been a
    change in the cardiac status of the veteran since.

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5.  For hyperthyroid heart disease, if atrial fibrillation is present,
    use arrhythmia worksheet. Also use endocrine worksheet if examining
    for hyperthyroidism.

6.  Describe the effects of the condition on the veteran\'s usual
    occupation and daily activities.

> 7\. Even when special examinations and tests (e.g., exercise testing)
> are not [required]{.underline}
>
> under the worksheet guidelines, they may be requested or conducted at
> the discretion
>
> of the examiner, when the examiner believes that the available
> information does not
>
> fully reflect the severity of the veteran's cardiovascular disability.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1.  Heart size and method of determination, heart rhythm and rate, heart
    sounds, blood pressure.

2.  Evidence of congestive heart failure - rales, edema, liver
    enlargement, etc.

D. **Diagnostic and Clinical Tests:**

1.  Chest X-ray, EKG, exercise stress test, echocardiogram, Holter
    monitor, thallium study, angiography, etc., as appropriate, and as
    required or indicated.

> 2\. Include results of all diagnostic and clinical tests conducted in
> the examination
>
> report, including status of left ventricular function, if measured.
>
> 3\. Valvular heart disease and endocarditis require documentation of
> diagnosis by
>
> physical findings and either echocardiogram, Doppler echocardiogram,
> or cardiac
>
> catheterization, if not already of record.
>
> 4\. Other types of heart disease must be documented by appropriate
> objective diagnostic
>
> tests.

E. **Diagnosis and Opinion:**

1.  Type of heart disease and etiology, if known.

2.  Type of surgery, if any, and results.

3.  If the veteran is service-connected for rheumatic heart disease and
    later develops non-service-connected arteriosclerotic heart disease,
    state, if possible, which cardiac findings can be attributed to each
    condition. If it is not possible to separate the signs and symptoms
    of one from the other, so state, and explain.

Signature: Date:

Compensation and Pension Examination

**arrhythmias**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

1.  Type of arrhythmia, onset of disorder, frequency and duration of
    attacks. Attacks confirmed by EKG or Holter monitor?.

2.  Pacemaker present? If so, when was it inserted, effectiveness, side
    effects?

3.  Other treatment? If so, type, effectiveness, side effects?

4.  For sustained ventricular arrhythmias, atrioventricular block, and
    implantable cardiac pacemakers (if ventricular arrhythmia or
    atrioventricular block was the reason for the pacemaker), the
    examiner must [provide the METs level, determined by exercise
    testing]{.underline}, at which symptoms of dyspnea, fatigue, angina,
    dizziness, or syncope result.

5.  Exercise testing is [not]{.underline} required for the above listed
    conditions in the following circumstances:

> a\. If exercise testing is medically contraindicated:

1.  In that case, provide the medical reason exercise testing cannot be
    conducted, and

2.  [Provide an estimate of the level of activity (expressed in METs and
    supported by specific examples]{.underline}, such as slow stair
    climbing, or shoveling snow) that results in dyspnea, fatigue,
    angina, dizziness, or syncope.

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b.  For sustained ventricular arrhythmia---from date of hospital
    admission for initial evaluation and medical therapy for a sustained
    ventricular arrhythmia or for ventricular aneurysmectomy, and for
    six months following discharge.

c.  With an automatic implantable Cardioverter-Defibrillator (AICD) in
    place.

d.  For two months following hospital admission for implantation or
    reimplantation of an implantable cardiac pacemaker.

e.  If an exercise test has been done within the past year, the results
    are of record, and there is no indication that there has been a
    change in the cardiac status of the veteran since.

> 6\. For implantable cardiac pacemakers---if [supraventricular
> arrhythmia]{.underline} was the reason
>
> for the pacemaker---describe any attacks of atrial fibrillation or
> other symptoms.
>
> 7\. Describe the effects of the condition on the veteran\'s usual
> occupation and daily
>
> activities.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1.  Heart size and method of determination, heart rate and rhythm, blood
    pressure.

2.  Status of cardiac function - evidence of congestive heart failure.

3.  Cardiac arrhythmia - type. Confirmed by EKG or Holter monitor?

D **Diagnostic and Clinical Tests:**

1\. EKG.

2\. Holter monitor, other tests as indicated.

> 3\. Chest X-ray, exercise stress test, echocardiogram, Holter monitor,
> thallium study, angiography, etc., as appropriate, and as required or
> indicated.
>
> 4\. Include results of all diagnostic and clinical tests conducted in
> the examination report, including status of left ventricular function,
> if measured.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**ARTERIES, VEINS, and Miscellaneous**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

For all conditions, comment on:

1.  Course, including onset of disorder, and any treatment, including
    surgery (type and when carried out).

2.  Symptoms.

3.  Is exercise and exertion precluded by the condition?

4.  Current treatment - type, effectiveness, side effects.

5.  If surgery has been done, report effectiveness and any residual or
    recurrent symptoms.

6.  Describe the effects of the condition on the veteran\'s usual
    occupation and daily activities.

> For aortic aneurysm, aneurysm of any large artery, aneurysm of any
> small artery, arteriovenous fistula, arteriosclerosis obliterans and
> thromboangiitis obliterans, additionally comment on:

1.  If lower extremities are affected, is there claudication, and, if
    so, after how many yards of walking on level ground at 2 miles per
    hour does it develop?

2.  Is there pain at rest?

> For Raynaud's phenomenon, angioneurotic edema, and erythromelalgia,
> additionally comment on:
>
> 1\. Describe a characteristic attack.
>
> 2\. Record the frequency, duration, and severity of characteristic
> attacks.
>
> 3\. Describe which parts of the body are affected. For angioneurotic
> edema,
>
> state whether laryngeal edema occurs and how frequently.
>
> 4\. What is the current treatment - type, dose, effectiveness, side
> effects?
>
> 5\. Describe the effects of the condition on the veteran\'s usual
> occupation and
>
> daily activities.
>
> For Varicose veins and Post-phlebitic syndrome of any etiology,
> additionally comment on:
>
> 1\. Describe symptoms, noting particularly whether aching, fatigue, or
>
> abnormal sensations are present in the leg at rest or after prolonged
>
> standing or walking.
>
> 2\. Are symptoms or edema relieved by elevation of the extremity,
>
> compression hosiery, or other measures?
>
> 3\. What is the current treatment - type, dose, effectiveness, side
> effects.
>
> 4\. What are the effects of the condition on the veteran's usual
> occupation
>
> and daily activities?
>
> For soft tissue sarcoma or other malignant neoplasms of vascular
> origin:

1.  Record date of diagnosis and pathologic diagnosis.

2.  Record type and dates of treatment. If treatment has been completed,
    state date of last treatment.

3.  Describe current symptoms. If treatment has been completed, describe
    residual or recurrent symptoms.

4.  What are the effects of the condition on the veteran's usual
    occupation and daily activities?

C. **Physical Examination (Objective Findings):**

1.  For aortic aneurysm, aneurysm of any large artery, aneurysm of any
    small artery, or arteriovenous fistula:

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a.  State size of aneurysm, cardiac status, including heart size and
    rate, pulse pressure, and whether there is evidence of high output
    failure.

b.  If extremities are affected, describe temperature and color, pulses,
    trophic changes, ulcers (deep or superficial?), edema, dermatitis,
    cellulitis.

c.  If lower extremities are affected, record ankle/brachial index
    (using Doppler).

d.  If surgery has been carried out, describe residual findings, using
    appropriate worksheet for the affected body system or organ.

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2.  For arteriosclerosis obliterans and thromboangiitis obliterans:

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a.  Describe each affected extremity separately.

b.  Record ankle/brachial index (using Doppler).

c.  Describe temperature and color of extremities, pulses, trophic
    changes, ulcers (deep or superficial?).

d.  If surgery has been carried out, describe any residuals or side
    effects of surgery.

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3.  For Raynaud's phenomenon, angioneurotic edema, and erythromelalgia:

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a.  Describe ulcers, autoamputations, and any other current findings.

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4.  For Varicose veins and Post-phlebitic syndrome of any etiology:

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a.  Describe any visible or palpable varicose veins.

b.  Describe extent of any ulcers, edema, stasis pigmentation, and
    eczema. If edema is present, is it boardlike? Is it persistent?

c.  Describe each affected extremity separately.

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5.  For soft tissue sarcoma or other malignant neoplasms of vascular
    origin:

> a\. Describe all current findings, whether pre- or post-treatment,
> including any residuals of treatment. Use other worksheets, if
> necessary, specific to the affected body system or organs.

D. **Diagnostic and Clinical Tests:**

1\. X-rays, Doppler vascular studies, angiogram, etc., as appropriate,
and if indicated.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**HYPERTENSION**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1.  Date of diagnosis.

2.  Symptoms, if any.

3\. Treatment - type, dosage, side effects.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1.  Blood pressure - If the diagnosis of hypertension has not been
    previously established, readings must be taken two or more times on
    at least three different days. If hypertension has been previously
    diagnosed, take three blood pressure readings on the day of
    examination.

2.  Cardiac status - size, function. If there is evidence of
    hypertensive heart disease, use Heart Worksheet.

3.  If arteriosclerotic complications of hypertension are present, use
    worksheet for the specific condition(s) found.

D. **Diagnostic and Clinical Tests:**

1.  X-rays or other tests, as indicated.

> 2\. Include results of all diagnostic and clinical tests conducted in
> the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**MOUTH, LIPS, AND TONGUE**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Disfigurement - if present, order [color photographs]{.underline}.

2\. Interference with mastication.

3\. Interference with speech - state extent.

4\. Absence of all or part of tongue - describe.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**ESOPHAGUS AND HIATAL HERNIA**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Dysphagia - for solids, liquids (frequency and extent).

2\. Pyrosis, epigastric or other pain, including associated substernal
or arm pain (frequency

and severity).

3\. Hematemesis or melena (describe any episodes).

4\. Reflux or regurgitation (frequency); for regurgitation, contents.

5\. Nausea, vomiting (frequency, precipitants).

6\. Current treatment - if dilatation, give frequency.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. General state of health, anemia.

2\. Nutrition, weight gain or loss.

D. **Diagnostic and Clinical Tests:**

1\. X-ray or endoscopic confirmation of obstruction, abnormal motility,
esophagitis,

reflux, etc.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. With obstruction or spasm, amenable to dilatation?

Signature: Date:

Compensation and Pension Examination

**INTESTINES (LARGE AND SMALL)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Weight gain or loss.

2\. Nausea and/or vomiting.

3\. Constipation, diarrhea (frequency, severity, duration, and episodic
or not?).

4\. For fistula - frequency, duration, and amount of fecal discharge.

.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Malnutrition, anemia, other evidence of debility.

2\. Abdominal pain - location, type, frequency, and duration.

3\. Current treatment - type, duration, response, and side effects.

4\. For fistula - location.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**LIVER, GALL BLADDER, AND PANCREAS**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:** This may be of particular importance
when hepatitis C (HCV) or chronic liver disease is claimed as related to
service.

B. **Medical History (Subjective Complaints):**

Comment on:

1.  Vomiting, hematemesis, or melena.

2.  Current treatment--type (medication, diet, enzymes, etc.), duration,
    response, side effects.

3.  Episodes of colic or other abdominal pain, fever, distention,
    nausea, or vomiting. Describe the duration, frequency, severity,
    treatment, and response to treatment.

4.  Fatigue, weakness, depression, or anxiety, and their severity.

5.  Past biliary tract surgery.

6.  When chronic liver disease is claimed:

-   Record history of and dates for any risk factors for liver disease,
    including transfusion or organ transplant before 1992, hemodialysis,
    tattoo, body piercing, intravenous (or intranasal cocaine) drug use,
    occupational blood exposure or other percutaneous blood exposure,
    high-risk sexual activity, etc. Intramuscular gamma globulin shots
    may be claimed as a risk factor for hepatitis C, but, to date, no
    transmission of HCV by this means has been shown.

-   Describe current symptoms of liver disease and onset of symptoms.

-   Provide history of any hepatitis in service and discuss its
    relationship to current liver disease.

-   Provide history of alcohol use/abuse, both current and past.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate, and fully describe current
findings:

1.  Ascites.

2.  Weight gain or loss, steatorrhea, malabsorption, malnutrition.

3.  Hematemesis or melena (describe any episodes).

4.  Pain or tenderness--location, type, precipitating factors.

5.  Liver size, superficial abdominal veins.

6.  Muscle strength and wasting.

7.  Any other signs of liver disease, e.g., palmar erythema, spider
    angiomata, etc.

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D.  **Diagnostic and Clinical Tests:**

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1.  For esophageal varices, X-ray, endoscopy, etc.

2.  For adhesions, X-ray to show partial obstruction, delayed motility.

3.  For gall bladder disease, X-ray or other objective confirmation.

4.  For liver disease:

-   Liver function tests (albumin, prothrombin time, bilirubin, AST,
    ALT, WBC, platelets).

-   Serologic tests for hepatitis (HBsAg, anti-HCV (EIA or ELISA)
    anti-HBc, ferritin, alpha-fetoprotein); and liver imaging
    (ultrasound or abdominal CT scan), as appropriate.

-   If hepatitis C is the suspected diagnosis, a positive EIA (enzyme
    immunoassay) test for hepatitis C should be confirmed by a RIBA
    (recombinant immunoblot assay) test **OR** by an HCV RNA test,
    either qualitative or quantitative. The diagnosis of hepatitis C
    infection should not be made unless such test results are in the
    record and support the diagnosis. A positive EIA test alone is not
    sufficient to establish the diagnosis, nor is a liver biopsy with a
    report that indicates it is "consistent with" hepatitis C infection.

-   With a diagnosis of hepatitis, name the specific type (A, B, C, or
    other), and for hepatitis B and C, provide an opinion as to which
    risk factor is the most likely cause. Support the opinion by
    discussing all risk factors in the individual and the rationale for
    your opinion. If you can not determine which risk factor is the
    likely cause, state that there is no risk factor that is more likely
    than another to be the cause, and explain.

-   With a diagnosis of cirrhosis, chronic hepatitis, liver malignancy,
    or other chronic liver disease, state the most likely etiology and
    the basis for your opinion. Address the relationship of the disease
    to active service, including any hepatitis or hepatitis risk factor
    that occurred in service. If you cannot determine the most likely
    etiology, cannot determine whether it is more likely than not that
    one of multiple risk factors is the cause, or cannot determine
    whether it is at least as likely as not that the liver disease is
    related to service, so state and explain.

5\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**DIGESTIVE CONDITIONS, MISCELLANEOUS**

**(Tuberculous Peritonitis, Inguinal Hernia, Ventral Hernia, Femoral
Hernia,**

**Visceroptosis, and Benign and Malignant New Growths)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

1\. Describe all hernia surgery and results.

2\. For malignancy, state type of treatment, dates of treatment,
including last date of

treatment if it has ended.

3\. For peritoneal tuberculosis, state date of diagnosis, treatment, and
date on which

inactivity was established.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. For inguinal or ventral hernia, state whether reducible, how well
supported by truss or

belt, and whether irremediable or inoperable.

2\. For ventral hernia, state size of hernia, extent of diastasis of
recti muscles, status of

muscles and fascia of abdominal wall.

3\. All residuals of malignancy, including residuals from treatment.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**RECTUM AND ANUS**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Degree of sphincter control.

2\. Extent and frequency of fecal leakage or involuntary bowel
movements- is a pad

needed?

3\. Bleeding or thrombosis of hemorrhoids - frequency and extent.

4\. Current treatment.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Colostomy.

2\. Evidence of fecal leakage.

3\. Size of lumen - rectum and anus.

4\. Signs of anemia.

5\. Fissures.

6\. If hemorrhoids - location, size, and if thrombosed.

7\. Evidence of bleeding.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**STOMACH, DUODENUM, AND PERITONEAL ADHESIONS**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Vomiting.

2\. Hematemesis or melena (describe any episodes).

3\. Treatment - type, duration, response, side effects.

4\. Circulatory disturbance after meals, hypoglycemic reactions (state
time of onset

in relation to meals, frequency).

5\. Diarrhea, constipation.

6\. Episodes of colic, distention, nausea, and/or vomiting - frequency,
duration, and

severity.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Specific site of any ulcer disease.

2\. Weight gain or loss.

3\. Signs of anemia.

4\. Pain or tenderness - location, type, precipitating factors.

D. **Diagnostic and Clinical Tests:**

1\. For gastritis, endoscopic evidence - describe hemorrhage, ulcerated
or

eroded areas.

2\. For adhesions, X-ray to show partial obstruction, delayed motility.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**GENITOURINARY EXAMINATION**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Lethargy, weakness, anorexia, weight loss or gain.

2\. Frequency (day or night, indicate voiding intervals), hesitancy,
stream, dysuria.

3\. Incontinence - if present, describe required frequency of absorbent
material and

whether an appliance is needed.

4\. Provide details of any history of:

a\. Surgery on any part of the urinary tract. Residuals? Impotence?

b\. Recurrent urinary tract infections.

c\. Renal colic or bladder stones.

d\. Acute nephritis.

e\. Hospitalization for urinary tract disease, if so, how many in the
past year?

f\. Treatment for malignancy, including type and date of last treatment.

5\. Treatments.

a\. Is catheterization needed? Intermittent or continuous?

b\. Frequency of dilations?

c\. Drainage procedures.

d\. Diet therapy - specify.

e\. Medications.

f\. Frequency per year of invasive and noninvasive procedures.

6\. Describe the effects of the condition(s) on the veteran\'s usual
occupation and daily

activities.

For Male Loss of Use of a Creative Organ

Comment on:

1\. Trauma/surgery affecting penis/testicles (e.g. vasectomy?)

2\. Local and/or systemic diseases affecting sexual function.

a\. Endocrine.

b\. Neurologic.

c\. Infections.

d\. Vascular.

e\. Psychological.

3\. Symptoms: Vaginal penetration with ejaculation possible?

4\. Past treatment:

a\. Medications, injections, implants, pump, counseling

b\. Effectiveness in allowing intercourse.

C. **Physical Examination (Objective Findings):**

Address each of the following, as appropriate, to the condition being
examined and fully

describe current findings:

1\. Blood pressure, cardiovascular examination, if indicated, describe
edema, to include

persistence.

2\. If on dialysis, type, where done, and how often?

3\. Inspection and palpation of penis, testicles, epididymis, and
spermatic cord. If there is

penis deformity, state whether there is loss of erectile power.
Inspection of anus and

digital exam of rectal walls, prostate, and seminal vesicles.

4\. Fistula.

5\. Specific residuals of genitourinary disease, including
post-treatment residuals of

malignancy.

6\. Testicular atrophy - size and consistency.

7\. Sensation and reflexes

8\. Peripheral pulses

D. **Diagnostic and Clinical Tests:**

1\. CBC.

2\. UA.

3\. Creatinine, BUN, albumin, electrolytes.

4\. Uroflowmetry, if indicated.

5\. Measurement of post-void residual, if indicated.

6\. Semen analysis, including sperm count and interpretation of results,
if applicable.

7\. Endocrine evaluation (glucose, TSH, testosterone, LH, FSH,
prolactin), if applicable.

8\. Psychiatric evaluation, if applicable.

9\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**GYNECOLOGICAL CONDITIONS AND DISORDERS OF THE BREAST**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Provide:

1\. Date of onset of symptoms.

2\. Describe symptoms, e.g., abnormal bleeding, vaginal discharge,
fever, pain, bowel or

bladder symptoms, etc.

3\. Treatments:

a\. Detail all breast and pelvic surgery.

b\. If a malignant process has been identified, provide:

\(1\) Date of confirmed diagnosis.

\(2\) Date of the last surgical, X-ray, antineoplastic chemotherapy,

radiation, or other therapeutic procedure.

\(3\) Expected date treatment regimen is to be completed.

\(4\) If already completed, provide date.

\(5\) Fully describe residuals.

c\. Detail hormonal and other medications and whether continuous
medication is

required, response, and side effects.

4\. Include complete menstrual history, pregnancy history, and urinary
tract history.

C. **Physical Examination (Objective Findings):**

Provide a full gynecological and breast examination (*unless only a
particular*

*condition or portion of the examination is requested*).

Address each of the following and fully describe current findings:

1\. Uterus.

a\. If post operative, state extent of surgery.

b\. If prolapse is present, is it through the introitus?

c\. If displaced, are there adhesions and/or menstrual disturbances.

2\. If rectovaginal fistula is present, describe extent and frequency of
leakage and

whether a pad is required.

3\. If urethrovaginal fistula is present, describe whether absorbent
material is required and

how often it must be changed.

4\. If rectocele, cystocele, or perineal relaxation is present, is it
due to pregnancy?

5\. Breasts.

If post-operative, Identify the type of surgery using the following
definitions:

a\. [Radical mastectomy]{.underline} - removal of the entire breast,
underlying pectoral muscles,

and regional lymph nodes up to the coracoclavicular ligament.

b\. [Modified radical mastectomy]{.underline} - removal of the entire
breast and axillary lymph

nodes (in continuity with the breast). Pectoral muscles are left intact.

c\. [Simple (or total) mastectomy]{.underline} - removal of all the
breast tissue, nipple, and a

small portion of the overlying skin, but lymph nodes and muscles are
left intact.

d\. [Wide local incision]{.underline} - includes partial mastectomy,
lumpectomy,

tylectomy, segmentectomy, and quadrantectomy. This means removal of a

portion of the breast tissue.

e\. Describe any alteration of size and form.

D. **Diagnostic and Clinical Tests:**

1\. CBC.

2\. Urinalysis.

3\. Laparoscopy is required to establish diagnosis of endometriosis and
to confirm bowel

or bladder involvement.

4\. Ultrasound, mammography, if indicated.

5\. Pap smear (if none within past year).

6\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**HEMIC DISORDERS**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Frequency and duration of crisis if sickle cell disease.

2\. Fatigability and/or weakness? (Is light manual labor precluded?)

3\. Headaches?

4\. History of infections? If yes, frequency and response to therapy?

5\. Shortness of breath? If yes, with what degree of exertion?

6\. Chest pain? Symptoms of claudication?

7\. History and frequency of transfusions, phlebotomy, bone marrow
transplant, myelo-

suppressant therapy.

8\. Symptoms of other end organ pathology?

9\. Disease activity (exacerbations/remission)? If there were
exacerbations, what was the

state of the veteran\'s health between exacerbations?

10\. Current and past treatment history including date and type of last
treatment?

11\. Syncope, lightheadedness.

C. **Physical Examination (Objective Findings):**

Address each of the following as appropriate to the condition being
examined and fully

describe current findings:

1\. Swelling of hands and/or feet (edema)?

2\. Presence of pallor (nail beds, mucosal surfaces, and skin)?

3\. Any other significant physical exam findings?

4\. Residuals of bone or other vascular infarction.

5\. Congestive heart failure?

D. **Diagnostic and Clinical Tests:**

1\. Hemoglobin level, platelet count, CBC.

2\. X-rays of bones or joints as indicated.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. Is the disease active?

Signature: Date:

Compensation and Pension Examination

**LYMPHATIC DISORDERS**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Disease activity (exacerbations/remission)? If there were
exacerbations, what was

the state of the veteran\'s health between exacerbations?

2\. Current and past treatment history including date and type of last
treatment, response,

side effects.

3\. If malignant neoplasm need date of diagnosis, date of treatment, or
if treatment

stopped when did it end.

4\. Location of disease.

5\. Current symptoms.

C. **Physical Examination (Objective Findings):**

Describe the residuals of each body system affected.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**SCARS**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

1\. Type of injury or infection causing the wound or scar, its date, the
treatment used and

the response to such treatment.

2\. Current symptoms.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings (for
each scar):

1\. Location, measurements (cm. x cm.), and shape of each scar.

2\. Tenderness.

3\. Adherence.

4\. Texture.

5\. Ulceration or breakdown of skin.

6\. Elevation or depression of scar.

7\. Extent of underlying tissue loss.

8\. Inflammation, edema, or keloid formation.

9\. Color of scar compared to normal areas of skin.

10\. Disfigurement.

11\. For each burn scar, state if due to a 2nd or 3rd degree burn.

12\. Limitation of function by scar.

13\. An attachment is provided in the Handout of Instructions for
Compensation and

Pension Examinations for plotting the location of scars.

D. **Diagnostic and Clinical Tests:**

1\. With disfigurement or disfiguring scar of head, face, or neck,
submit

[color photographs]{.underline}.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

SKIN DISEASES (Other Than Scars)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Onset of disease and course - intermittent, constant.

2\. Current treatment - include side effects.

3\. Symptoms - pruritus, pain, etc.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Extent of disease - specify what exposed areas are involved and how
large they are.

2\. Ulceration, exfoliation, or crusting.

3\. Associated systemic or nervous manifestations.

D. **Diagnostic and Clinical Tests:**

1\. Biopsy, scrapings if indicated.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. Take [color photographs]{.underline} if disfigurement or disfiguring
scars are present.

Signature: Date:

Compensation and Pension Examination

**ENDOCRINE DISEASES, MISCELLANEOUS**

**(Benign and Malignant Neoplasms, Hyperpituitarism,**

**Hyperaldosteronism, and Pheochromocytoma)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B**. Medical History (Subjective Complaints):**

Comment on:

1\. Date of diagnosis and how established.

2\. Fatigability.

3\. Headaches.

4\. Changes in vision.

5\. Neurologic, cardiovascular, or gastrointestinal symptoms.

6\. Treatments (surgery, medications, hormones), including dose,
frequency, response,

side effects. For malignancy, provide date of completion of treatment
for malignancy.

7\. Weight gain or loss.

8\. Excessive thirst, frequency of urination.

9\. Describe the effects of the condition(s) on the veteran\'s usual
occupation and daily

activities.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. For hypoparathyroidism, thyroid surgery scar?

2\. For diabetes insipidus, signs of dehydration?

3\. For Addison\'s disease, muscle strength, blood pressure, skin
pigmentary changes.

Number of crises (with peripheral vascular collapse) or episodes (less
acute and severe

than crisis - no peripheral vascular collapse).

4\. For pluriglandular syndromes, see examinations for glands affected.

5\. Describe all residuals of benign or malignant neoplasm, including
those related to

treatment.

6\. Is the disease active or in remission?

7\. For hyperparathyroidism, history of kidney stones. History of
demineralization of

skeleton.

D. **Diagnostic and Clinical Tests:**

Provide, as appropriate:

1\. Blood and urinary calcium.

2\. X-ray of bones to confirm decalcification.

3\. Glucose tolerance test, if necessary.

4\. Antidiuretic hormone level.

5\. Serum and urine electrolytes.

6\. Urine specific gravity.

7\. Serum cortisol.

8\. Serum creatinine.

9\. Serum glucose.

10\. ACTH test.

11\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**Thyroid AND PARATHYROID** **diseases**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B**. Medical History (Subjective Complaints):**

Comment on:

1\. Date diagnosis established.

2\. Fatigability.

3\. Mental assessment.

4\. Neurologic, cardiovascular, or gastrointestinal symptoms.

5\. Treatments (surgery, medications, hormones), including dose,
frequency, response,

side effects. For C-cell hyperplasia, provide date of completion of any
treatment for

malignancy.

6\. Symptoms due to pressure (on larynx, esophagus, etc.).

7\. Cold or heat intolerance.

8\. Constipation.

9\. Weight gain or loss.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Thyroid size.

2\. Pulse and blood pressure.

3\. Eye and vision abnormalities.

4\. Muscle strength.

5\. Tremor.

6\. Myxedema.

7\. All other residuals of thyroid disease or its treatment.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. T4, T3, TSH, and/or other thyroid function tests, if needed.

2\. If thyroidectomy scar is disfiguring, order [color
photograph]{.underline}.

3\. Thyroid scan, if indicated.

4\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Comment on:

1\. Is the disease active or in remission?

Signature: Date:

Compensation and Pension Examination

**CUSHING\'S SYNDROME**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B**. Medical History (Subjective Complaints):**

Comment on:

1\. Date diagnosis established.

2\. Weakness.

3\. Etiology ? Iatrogenic?

4\. Treatments (surgery, medication, etc.), dose, frequency, response,
side effects.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Muscle strength.

2\. Vascular fragility.

3\. Gastrointestinal.

4\. Blood Pressure.

5\. Striae.

6\. Weight gain or loss.

7\. Moonface.

8\. Glucose metabolism.

9\. After control, describe adrenal insufficiency, cardiovascular,
psychiatric, skin, or

skeletal complications or residuals.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. CT of brain or X-ray of sella turcica.

2\. Serum and urine cortisol levels.

3\. High and low dose dexamethasone suppression test.

4\. X-rays if osteoporosis suspected.

5\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Comment on:

1\. Is the disease active or in remission?

Signature: Date:

Compensation and Pension Examination

**ACROMEGALY**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B**. Medical History (Subjective Complaints):**

Comment on:

1\. Date diagnosis established.

2\. Joint pains.

3\. Changes in vision.

4\. Headaches (severity and frequency).

5\. Cardiac symptoms.

6\. Change in shoe, glove, or hat size.

7\. Symptoms of glucose intolerance.

8\. Treatments.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Arthropathy.

2\. Vascular fragility.

3\. Evidence of increased intracranial pressure.

4\. Size of acral parts, long bones.

5\. Visual impairment, including visual fields.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. CT of brain or X-ray of sella turcica.

2\. Glucose tolerance test.

3\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Comment on:

1\. Is the disease active or in remission?

Signature: Date:

Compensation and Pension Examination

**DIABETES MELLITUS**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Age of onset.

2\. Frequency of ketoacidosis or hypoglycemic reactions (hospitalization
required?).

3\. Restricted diet, weight loss or gain since last exam.

4\. Describe any restriction of activities.

5\. Visual problems.

6\. Vascular or cardiac symptoms.

7\. Neurologic symptoms.

8\. Treatment - oral hypoglycemic, insulin (frequency of injections).

9\. Frequency of visits to diabetic care provider.

10\. Other symptoms, such as anal pruritus, loss of strength.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Blood pressure, other cardiovascular findings, including status of
peripheral vessels.

2\. Neurologic examination.

3\. Eye examination.

4\. Skin examination.

5\. Examination of extremities, including feet.

6\. State if the veteran has bladder or bowel functional impairment. If
present, state

whether partial or total, intermittent or constant and what measures are
taken as a

result of the impairment.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. Renal function tests, including 24 hour urine test for protein if
renal involvement is

uncertain.

2\. Blood sugar.

3\. Urinalysis.

4\. Glucose tolerance test, if necessary to establish the diagnosis.

5\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Comment on:

1\. All complications noted - visual, cardiac, vascular, nephrologic,
neurologic (including

both peripheral neuropathy and cerebral effects), amputations. See
examination

worksheets for the conditions found.

Signature: Date:

Compensation and Pension Examination

**BRAIN AND SPINAL CORD**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. If flare-ups exist, describe precipitating factors, aggravating
factors, alleviating factors,

alleviating medications, frequency, severity, duration and whether the
flare-ups include

pain, weakness, fatigue or functional loss.

2\. Current treatment, response, and side effects.

3\. State whether condition has stabilized.

4\. Seizures - type, frequency.

5\. Headache, dizziness, etc.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. If a tumor is or was present, note location, type, and whether or
not it is malignant. If

a malignancy is present but is now cured or in remission, report the
date of last

surgery, radiation therapy, chemotherapy or other treatment.

2\. Describe in detail the motor and sensory impairment of all affected
nerves.

3\. Describe in detail any functional impairment of the peripheral and
autonomic systems.

4\. [A detailed assessment of each affected joint is
required]{.underline}.

a\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance.

b\. If the joint is painful on motion, state at what point in the range
of motion pain

begins and ends.

c\. State to what extent, if any, the range of motion or function is
[additionally]{.underline}

limited by pain, fatigue, weakness, or lack of endurance. If more than
one of

these is present, state, if possible, which has the major functional
impact.

5\. Describe any psychiatric manifestations in detail - see worksheets
for mental disorders.

6\. Eye examination.

7\. State if the veteran has bladder or bowel functional impairment. If
present, state

whether partial or total, intermittent or constant and what measures are
taken as a

result of the impairment.

8\. State if the veteran is capable of managing his or her benefit
payments in his or her own

best interest without restriction. (A physical disability which prevents
the veteran from

attending to financial matters in person is not a proper basis for a
finding of

incompetency unless the veteran is, by reason of that disability,
incapable of directing

someone else in handling the individual\'s financial affairs.)

9\. If smell or taste is affected, also complete the appropriate
worksheet.

D. **Diagnostic and Clinical Tests:**

1\. Skull X-rays to measure bony defect, if there was surgery; spine
X-rays if there was

spinal cord surgery.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**CRANIAL NERVES**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. If flare-ups exist, describe precipitating factors, aggravating
factors, alleviating factors,

alleviating medications, frequency, severity, duration and whether the
flare-ups include

pain, weakness, fatigue or functional loss.

2\. Current treatment, response, side effects.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. Identify the nerve and the side.

2\. Identify the disorder (i.e., paralysis, neuritis, neuralgia).

3\. Describe in detail specific motor and sensory impairment,
quantifying as much as

possible.

4\. If smell or taste is affected, please also complete the appropriate
worksheet.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. State etiology.

Signature: Date:

Compensation and Pension Examination

**NEUROLOGICAL DISORDERS, MISCELLANEOUS**

**(Migraine, Tic, Paramyoclonus Multiplex,**

**Sydenham\'s and Huntington\'s Chorea, and Athetosis)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Onset and course - If flare-ups exist, describe precipitating
factors, aggravating factors,

alleviating factors, alleviating medications, frequency, severity,
duration, and whether

the flare-ups include pain, weakness, fatigue or functional loss.

2\. Current treatment, response, side effects.

C. **Physical Examination (Objective Findings):**

1\. If [Migraine:]{.underline} - Obtain the history of frequency and
duration of attacks and description

of level of activity the veteran can maintain during the attacks. For
example, state if

the attacks are prostrating in nature or if ordinary activity is
possible.

2\. If [Tics and Paramyoclonus Complex:]{.underline} - Ascertain the
muscle group(s) involved and

obtain the best possible history of frequency and severity of attacks.
State the effects

on daily activities.

3\. If [Chorea, Choreiform Disorders, etc.:]{.underline} - Describe
manifestations by impairment of

strength, coordination, tremor, etc., with particular attention to the
effects of the

performance of ordinary activities of daily living.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**PERIPHERAL NERVES**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Onset and course - If flare-ups exist, describe precipitating
factors, aggravating factors,

alleviating factors, alleviating medications, frequency, severity,
duration and whether

the flare-ups include pain, weakness, fatigue or functional loss.

2\. Current treatment, response, and side effects.

3\. Paresthesias, dysesthesias, other sensory abnormalities.

4\. Describe extent to which condition interferes with daily activity.

5\. Specify nerves involved.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. If the disability is the result of brain disease or injury, spinal
cord disease or injury,

cervical disc disease, or trauma to the nerve roots themselves:

a\. Report sensory and motor impairment by reference to the distribution
of the

affected groups as paralysis, neuritis or neuralgia.

b\. Report each affected extremity separately.

2\. If disability is NOT from the above:

a\. Identify the specific major nerve involved, localize the lesion and
describe

specific impairment of motor and sensory function, fine motor control,
etc.

b\. Characterize as paralysis, neuritis or neuralgia, and indicate
whether any muscle

wasting or atrophy represents direct effect of nerve damage or merely
disuse.

c\. Report each affected extremity separately.

3\. For each joint that is affected:

a\. Using a goniometer, measure the [passive]{.underline} and
[active]{.underline} range of motion, including

movement against gravity and against strong resistance.

b\. If the joint is painful on motion, state at what point in the range
of motion pain

begins and ends.

c\. State to what extent, if any, the range of motion or function is
[additionally]{.underline}

[limited]{.underline} by pain, fatigue, weakness, or lack of endurance.
If more than one of

these is present, state, if possible, which has the major functional
impact.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. State etiology.

Signature: Date:

Compensation and Pension Examination

**EPILEPSY AND NARCOLEPSY**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. Discuss precipitating factors, aggravating factors, alleviating
factors.

2\. Current treatment, response, side effects.

3\. State the frequency and type of seizures or episodes of narcolepsy
during the past 12

months, including any change in frequency pattern. If possible, record
the actual

number of seizures in each calendar month. If the veteran keeps a
seizure diary, record

dates of seizures.

4\. Discuss the effect of epilepsy or narcolepsy on daily activities,
including the effects of

medications.

C. **Physical Examination (Objective Findings):**

1\. Order a psychiatric examination if there are indications of a mental
disorder associated

with epilepsy.

D. **Diagnostic and Clinical Tests:**

1\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. If the diagnosis is NOT established or is questioned, schedule any
necessary special

studies, including admission for a period of examination and
observation, as

appropriate to provide a definitive diagnosis.

Signature: Date:

Compensation and Pension Examination

**Initial Evaluation for Post-traumatic Stress Disorder (PTSD)**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

# **A. Identifying Information**

-   age

-   ethnic background

-   era of military service

-   reason for referral (original exam to establish PTSD diagnosis and
    related psychosocial impairment; re-evaluation of status of existing
    service-connected PTSD condition)

#  {#section .unnumbered}

# **B. Sources of Information** {#b.-sources-of-information .unnumbered}

-   records reviewed (C-file, DD-214, medical records, other
    documentation)

-   review of social-industrial survey completed by social worker

-   statements from collaterals

-   administration of psychometric tests and questionnaires (identify
    here)

**C.** **Review of Medical Records:**

**1. Past Medical History:**

a.  Previous hospitalizations and outpatient care.

b.  Complete medical history is required, including history since
    discharge from military service.

c.  Review of Claims Folder is required on initial exams to establish or
    rule out the diagnosis.

**2. Present Medical History** - over the past one year.

> a\. Frequency, severity and duration of medical and psychiatric
> symptoms.
>
> b\. Length of remissions, to include capacity for adjustment during
> periods of remissions.

**D. Examination (Objective Findings):**

> Address each of the following and fully describe:

**History (Subjective Complaints):**

Comment on:

# **Premilitary History (refer to social-industrial survey if completed)**

-   describe family structure and environment where raised (identify
    constellation of family members and quality of relationships)

-   quality of peer relationships and social adjustment (e.g.,
    activities, achievements, athletic and/or extracurricular
    involvement, sexual involvements, etc.)

-   education obtained and performance in school

-   employment

-   legal infractions

-   delinquency or behavior conduct disturbances

-   substance use patterns

-   significant medical problems and treatments obtained

-   family psychiatric history

-   exposure to traumatic stressors (see CAPS trauma assessment
    checklist)

-   summary assessment of psychosocial adjustment and progression
    through developmental milestones (performance in employment or
    schooling, routine responsibilities of self-care, family role
    functioning, physical health, social/interpersonal relationships,
    recreation/leisure pursuits).

# **Military History** {#military-history .unnumbered}

-   branch of service (enlisted or drafted)

-   dates of service

-   dates and location of war zone duty and number of months stationed
    in war zone

-   Military Occupational Specialty (describe nature and duration of
    job(s) in war zone

-   highest rank obtained during service (rank at discharge if
    different)

-   type of discharge from military

-   describe routine combat stressors veterans was exposed to (refer to
    Combat Scale)

-   combat wounds sustained (describe)

-   **clearly describe specific stressor event(s) veteran considered
    particularly traumatic**. Clearly describe the stressor.
    Particularly if the stressor is a type of personal assault,
    including sexual assault, provide information, with examples, if
    possible.

-   indicate overall level of traumatic stress exposure (high, moderate,
    low) based on frequency and severity of incident exposure (refer to
    trauma assessment scale scores described in Appendix B).

-   citations or medals received

-   disciplinary infractions or other adjustment problems during
    military

**NOTE**: Service connection for post-traumatic stress disorder (PTSD)
requires medical evidence establishing a diagnosis of the condition that
conforms to the diagnostic criteria of DSM-IV, credible supporting
evidence that the claimed in-service stressor actually occurred, and a
link, established by medical evidence, between current symptomatology
and the claimed in-service stressor. It is the responsibility of the
examiner to indicate the traumatic stressor leading to PTSD, if he or
she makes the diagnosis of PTSD. *Crucial in this description are
specific details of the stressor, with names, dates, and places linked
to the stressor, so that the rating specialist can confirm that the
cited stressor occurred during active duty.*

A diagnosis of PTSD cannot be adequately documented or ruled out without
obtaining a detailed military history and reviewing the claims folder.
This means that initial review of the folder prior to examination, the
history and examination itself, and the dictation for an examination
initially establishing PTSD will often require more time than for
examinations of other disorders. Ninety minutes to two hours on an
initial exam is normal.

# 

# **Post-Military Trauma History (refer to social-industrial survey if** 

# **completed)**

-   describe post-military traumatic events (see CAPS trauma assessment
    checklist)

-   describe psychosocial consequences of post-military trauma
    exposure(s) (treatment received, disruption to work, adverse health
    consequences)

# **Post-Military Psychosocial Adjustment (refer to social-industrial survey if completed)** {#post-military-psychosocial-adjustment-refer-to-social-industrial-survey-if-completed .unnumbered}

-   legal history (DWIs, arrests, time spent in jail)

-   educational accomplishment

-   employment history (describe periods of employment and reasons)

-   marital and family relationships (including quality of relationships
    with children)

-   degree and quality of social relationships

-   activities and leisure pursuits

-   problematic substance abuse (lifetime and current)

-   significant medical disorders (resulting pain or disability; current
    medications)

-   treatment history for significant medical conditions, including
    hospitalizations

-   history of inpatient and/or outpatient psychiatric care (dates and
    conditions treated)

-   history of assaultiveness

-   history of suicide attempts

-   summary statement of current psychosocial functional status
    (performance in employment or schooling, routine responsibilities of
    self care, family role functioning, physical health,
    social/interpersonal relationships, recreation/leisure pursuits)

    **E. Mental Status Examination**

    Conduct a [brief]{.underline} mental status examination aimed at
    screening for DSM-IV mental disorders. Describe and fully explain
    the existence, frequency and extent of the following signs and
    symptoms, or any others present, and relate how they interfere with
    employment and social functioning:

-   Impairment of thought process or communication.

-   Delusions, hallucinations and their persistence.

-   Eye Contact, interaction in session, and inappropriate behavior
    cited with examples.

-   Suicidal or homicidal thoughts, ideations or plans or intent.

-   Ability to maintain minimal personal hygiene and other basic
    activities of daily living.

-   Orientation to person, place and time.

-   Memory loss, or impairment (both short and long-term).

-   Obsessive or ritualistic behavior which interferes with routine
    activities and describe any found.

-   Rate and flow of speech and note any irrelevant, illogical, or
    obscure speech patterns and whether constant or intermittent.

-   Panic attacks noting the severity, duration, frequency and effect on
    independent functioning and whether clinically observed or good
    evidence of prior clinical or equivalent observation is shown.

-   Depression, depressed mood or anxiety.

-   Impaired impulse control and its effect on motivation or mood.

-   Sleep impairment and describe extent it interferes with daytime
    activities.

-   Other disorders or symptoms and the extent they interfere with
    activities, particularly:

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-   mood disorders (especially major depression and dysthymia)

-   substance use disorders (especially alcohol use disorders)

-   anxiety disorders (especially panic disorder, obsessive-compulsive
    disorder, generalized anxiety disorder)

-   somatoform disorders

-   personality disorders (especially antisocial personality disorder
    and borderline personality disorder)

    Specify onset and duration of symptoms as acute, chronic, or with
    delayed onset.

# **F. Assessment of PTSD** {#f.-assessment-of-ptsd .unnumbered}

-   state whether or not the veteran meets the DSM-IV stressor criterion

-   identify behavioral, cognitive, social, affective, or somatic change
    veteran attributes to stress exposure

-   describe specific PTSD symptoms present (symptoms of trauma
    re-experiencing, avoidance/numbing, heightened physiological
    arousal, and associated features \[e.g., disillusionment and
    demoralization\])

-   specify onset, duration, typical frequency, and severity of symptoms

# **G. Psychometric Testing Results** {#g.-psychometric-testing-results .unnumbered}

-   provide psychological testing if deemed necessary

-   provide specific evaluation information required by the rating board
    or on a **BVA Remand**.

-   comment on validity of psychological test results

-   provide scores for PTSD psychometric assessments administered

-   state whether PTSD psychometric measures are consistent or
    inconsistent with a diagnosis of PTSD, based on normative data and
    established \"cutting scores\" (cutting scores that are consistent
    with or supportive of a PTSD diagnosis are as follows: PCL
    [\>]{.underline} 50; Mississippi Scale [\>]{.underline} 107; MMPI
    PTSD subscale a score \> 28; MMPI code type: 2-8 or 2-7-8)

-   state degree of severity of PTSD symptoms based on psychometric data
    (mild, moderate, or severe)

-   describe findings from psychological tests measuring problems other
    than PTSD (MMPI, etc.)

    **H. Diagnosis:**

    1\. The Diagnosis must conform to DSM-IV and be supported by the
    findings on the examination report.

    2\. If there are multiple mental disorders, delineate to the extent
    possible the symptoms associated with each and a discussion of
    relationship.

    3\. Evaluation is based on the effects of the signs and symptoms on
    occupational and social functioning.

    **NOTE:** VA is prohibited by statute from paying compensation for a
    disability that is a result of the veteran\'s own **ALCOHOL OR DRUG
    ABUSE**, whether based on direct service connection, secondary
    service connection, or aggravation by a service-connected condition.
    Therefore, when alcohol or drug abuse accompanies or is associated
    with another mental disorder, separate, to the extent possible, the
    effects of the alcohol or drug abuse from the effects of the other
    mental disorder(s). If it is not possible to separate the effects,
    explain why.

#  {#section-2 .unnumbered}

# **I.** **Diagnostic Status** {#i.-diagnostic-status .unnumbered}

Axis I disorders

Axis II disorders

Axis III disorders

Axis IV (psychosocial and environmental problems)

Axis V (GAF score - current)

**J. Global Assessment of Functioning** (**GAF):**

**NOTE:** The complete multi-axial format as specified by DSM-IV may be
required by BVA REMAND or specifically requested by the rating
specialist. If so, include the GAF score and note whether it refers to
current functioning. A BVA REMAND may also request, in addition to an
overall GAF score, that a separate GAF score be provided for each mental
disorder present when there are multiple Axis I or Axis II diagnoses and
not all are service-connected. If separate GAF scores can be given, an
explanation and discussion of the rationale is needed. If it is not
possible, an explanation as to why not is needed. (See the above note
pertaining to alcohol or drug abuse, the effects of which cannot be used
to assess the effects of a service-connected condition.)

DSM-IV is only for application from 11/7/96 on. Therefore, when
applicable note whether the diagnosis of PTSD was supportable under
DSM-III-R prior to that date. The prior criteria under DSM-III-R are
provided as an attachment.

**K. Competency:** Competency, for benefits purposes, has a special
meaning, and refers [only]{.underline} to veterans' ability to manage
benefit payments in their own best interests without restriction, and
not to any other subject. State whether the veteran is capable of
managing his/her or her benefit payments in the individual\'s own best
interests (a physical disability which prevents the veteran from
attending to financial matters in person is not a proper basis for a
finding of incompetency unless the veteran is, by reason of that
disability, incapable of directing someone else in handling the
individual\'s financial affairs).

**L. Other Opinion:** Furnish any other specific opinion requested by
the rating board or BVA remand (furnish the complete rationale and
citation of medical texts or treatise supporting opinion, if medical
literature review was undertaken). If the requested opinion is medically
not ascertainable on exam or testing please state **why**. If the
requested opinion can not be expressed without resorting to speculation
or making improbable assumptions say so, and explain why. If the opinion
asks \" \... is it at least as likely as not \... \", fully explain the
clinical findings and rationale for the opinion.

#  {#section-3 .unnumbered}

# **M**. **Integrated Summary and Conclusions** {#m.-integrated-summary-and-conclusions .unnumbered}

-   Describe changes in [psychosocial functional status]{.underline} and
    [quality of life]{.underline} following trauma exposure (performance
    in employment or schooling, routine responsibilities of self care,
    family role functioning, physical health, social/interpersonal
    relationships, recreation/leisure pursuits)

-   Describe linkage between PTSD symptoms and aforementioned changes in
    impairment in functional status and quality of life. *Particularly
    in cases where a veteran is unemployed, specific details about the
    effects of PTSD and its symptoms on employment are especially
    important.*

-   If possible, describe extent to which disorders other than PTSD
    (e.g., substance use disorders) are independently responsible for
    impairment in psychosocial adjustment and quality of life. If this
    is not possible, explain why (e.g., substance use had onset after
    PTSD and clearly is a means of coping with PTSD symptoms).

-   If possible, describe pre-trauma risk factors or characteristics
    than may have rendered the veteran vulnerable to developing PTSD
    subsequent to trauma exposure.

-   If possible, state prognosis for improvement of psychiatric
    condition and impairments in functional status.

-   Comment on whether veteran should be rated as competent for VA
    purposes in terms of being capable of managing his/her benefit
    payments in his/her own best interest.

> **Signature: Date:**

Compensation and Pension Examination

**Review examination for Post-traumatic stress disorder (PTSD)**

**Name: SSN:**

**Date of Exam: C-number:**

**Place of Exam:**

**A: Review of Medical Records.**

**B.** **Medical History since last exam:**

Comment on:

1.  Hospitalizations and outpatient care from the time between last
    rating examination to the present, unless the purpose of this
    examination is to ESTABLISH service connection, then the complete
    medical history since discharge from military service is required.

2.  Frequency, severity and duration of psychiatric symptoms.

3.  Length of remissions from psychiatric symptoms, to include capacity
    for adjustment during periods of remissions.

4.  Treatments including statement on effectiveness and side effects
    experienced.

5.  [Subjective Complaints]{.underline}: Describe fully.

**C. Psychosocial Adjustment since the last exam**

-   legal history (DWIs, arrests, time spent in jail)

-   educational accomplishment

-   extent of time lost from work over the past 12 month period and
    social impairment. If employed, identify current occupation and
    length of time at this job. *If unemployed, note in
    [complaints]{.underline} whether veteran contends it is due to the
    effects of a mental disorder. Further indicate following
    **DI[AGNOSIS]{.smallcaps}** what factors, and objective findings
    support or rebut that contention.*

-   marital and family relationships (including quality of relationships
    with spouse and children)

-   degree and quality of social relationships

-   activities and leisure pursuits

-   problematic substance abuse

-   significant medical disorders (resulting pain or disability; current
    medications)

-   history of violence / assaultiveness

-   history of suicide attempts

-   summary statement of current psychosocial functional status
    (performance in employment or schooling, routine responsibilities of
    self care, family role functioning, physical health,
    social/interpersonal relationships, recreation/leisure pursuits)

# **D. Mental Status Examination**  {#d.-mental-status-examination .unnumbered}

Conduct a [brief]{.underline} mental status examination aimed at
screening for DSM-IV mental disorders. Describe and fully explain the
existence, frequency and extent of the following signs and symptoms, or
any others present, and relate how they interfere with employment and
social functioning:

-   Impairment of thought process or communication.

-   Delusions, hallucinations and their persistence.

-   Eye contact, interaction in session, and inappropriate behavior
    cited with examples.

-   Suicidal or homicidal thoughts, ideations or plans or intent.

-   Ability to maintain minimal personal hygiene and other basic
    activities of daily living.

-   Orientation to person, place and time.

-   Memory loss, or impairment (both short and long-term).

-   Obsessive or ritualistic behavior which interferes with routine
    activities and describe any found.

-   Rate and flow of speech and note any irrelevant, illogical, or
    obscure speech patterns and whether constant or intermittent.

-   Panic attacks noting the severity, duration, frequency and effect on
    independent functioning and whether clinically observed or good
    evidence of prior clinical or equivalent observation is shown.

-   Depression, depressed mood or anxiety.

-   Impaired impulse control and its effect on motivation or mood.

-   Sleep impairment and describe extent it interferes with daytime
    activities.

-   Other disorders or symptoms and the extent they interfere with
    activities, particularly:

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-   mood disorders (especially major depression and dysthymia)

-   substance use disorders (especially alcohol use disorders)

-   anxiety disorders (especially panic disorder, obsessive-compulsive
    disorder, generalized anxiety disorder)

-   somatoform disorders

-   personality disorders (especially antisocial personality disorder
    and borderline personality disorder)

# **E. Assessment of PTSD** {#e.-assessment-of-ptsd .unnumbered}

-   state whether or not the veteran currently meets the DSM-IV stressor
    criterion

-   identify behavioral, cognitive, social, affective, or somatic
    symptoms veteran attributes to PTSD

-   describe specific PTSD symptoms present (symptoms of trauma
    re-experiencing, avoidance/numbing, heightened physiological
    arousal, and associated features \[e.g., disillusionment and
    demoralization\])

-   specify typical frequency and severity of symptoms

# **F. Psychometric Testing Results** {#f.-psychometric-testing-results .unnumbered}

-   provide psychological testing if deemed necessary

-   provide specific evaluation information required by the rating board
    or on a **BVARemand**.

-   comment on validity of psychological test results

-   provide scores for PTSD psychometric assessments administered

-   state whether PTSD psychometric measures are consistent or
    inconsistent with a diagnosis of PTSD, based on normative data and
    established \"cutting scores\" (cutting scores that are consistent
    with or supportive of a PTSD diagnosis are as follows: PCL
    [\>]{.underline} 50; Mississippi Scale [\>]{.underline} 107; MMPI
    PTSD subscale a score \> 28; MMPI code type: 2-8 or 2-7-8)

-   state degree of severity of PTSD symptoms based on psychometric data
    (mild, moderate, or severe)

-   describe findings from psychological tests measuring problems other
    than PTSD (MMPI, etc.)

**G. Diagnosis:**

> 1\. The Diagnosis must conform to DSM-IV and be supported by the
> findings on the examination report.
>
> 2\. If there are multiple mental disorders, delineate to the extent
> possible the symptoms associated with each and a discussion of
> relationship.
>
> 3\. Evaluation is based on the effects of the signs and symptoms on
> occupational and social functioning.
>
> **NOTE:** VA is prohibited by statute from paying compensation for a
> disability that is a result of the veteran\'s own ALCOHOL OR DRUG
> ABUSE, whether based on direct service connection, secondary service
> connection, or aggravation by a service-connected condition.
> Therefore, when alcohol or drug abuse accompanies or is associated
> with another mental disorder, separate, to the extent possible, the
> effects of the alcohol or drug abuse from the effects of the other
> mental disorder(s). If it is not possible to separate the effects,
> explain why.

# 

# **H. Diagnostic Status**

> Axis I disorders
>
> Axis II disorders
>
> Axis III disorders
>
> Axis IV (psychosocial and environmental problems)
>
> Axis V (GAF score: current)

**I. Global Assessment of Functioning** (**GAF):**

> **NOTE:** The complete multi-axial format as specified by DSM-IV may
> be required by BVA REMAND or specifically requested by the rating
> specialist. If so, include the GAF score and note whether it refers to
> current functioning. A BVA REMAND may also request, in addition to an
> overall GAF score, that a separate GAF score be provided for each
> mental disorder present when there are multiple Axis I or Axis II
> diagnoses and not all are service-connected. If separate GAF scores
> can be given, an explanation and discussion of the rationale is
> needed. If it is not possible, an explanation as to why not is needed.
> (See the above note pertaining to alcohol or drug abuse, the effects
> of which cannot be used to assess the effects of a service-connected
> condition.)

**J.** **Competency:** Competency, for benefits purposes, has a special
meaning, and refers [only]{.underline} to veterans' ability to manage
benefit payments in their own best interests without restriction, and
not to any other subject. State whether the veteran is capable of
managing his/her or her benefit payments in the individual\'s own best
interests (a physical disability which prevents the veteran from
attending to financial matters in person is not a proper basis for a
finding of incompetency unless the veteran is, by reason of that
disability, incapable of directing someone else in handling the
individual\'s financial affairs).

**K**. **Other Opinion:** Furnish any other specific opinion requested
by the rating board or BVA remand (i.e., furnish the complete rationale
and citation of medical texts or treatise supporting opinion, if medical
literature review was undertaken). If the requested opinion is medically
not ascertainable on exam or testing please state **why**. If the
requested opinion can not be expressed without resorting to speculation
or making improbable assumptions say so, and explain why. If the opinion
asks \" \... is it at least as likely as not \... \", fully explain the
clinical findings and rationale for the opinion.

# **L. Integrated Summary and Conclusions**

1.  Describe changes in [psychosocial functional status]{.underline} and
    [quality of life]{.underline} since the last exam (performance in
    employment or schooling, routine responsibilities of self care,
    family role functioning, physical health, social/interpersonal
    relationships, recreation/leisure pursuits).

2.  Describe linkage between PTSD symptoms and aforementioned changes in
    impairment in functional status and quality of life. *Particularly
    in cases where a veteran is unemployed, specific details about the
    effects of PTSD and its symptoms on employment are especially
    important.*

3.  If possible, describe extent to which disorders other than PTSD
    (e.g., substance use disorders) are independently responsible for
    impairment in psychosocial adjustment and quality of life. If this
    is not possible, explain why (e.g., substance use had onset after
    PTSD and clearly is a means of coping with PTSD symptoms).

4.  If possible, state prognosis for improvement of psychiatric
    condition and impairments in functional status.

5.  Comment on whether veteran should be rated as competent for VA
    purposes in terms of being capable of managing his/her benefit
    payments in his/her own best interest.

**Signature: Date:**

Compensation and Pension Examination

**MENTAL DISORDERS** (except PTSD and Eating Disorders)

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A: **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. [Past Medical History:]{.underline}

a\. Previous hospitalizations and outpatient care.

b\. Medical and occupational history from the time between last rating
examination

and the present, unless the purpose of this examination is to ESTABLISH

service connection, then the complete medical history since discharge
from

military service is required.

2\. [Present Medical, Occupational, and Social History]{.underline} -
over the past one year.

a\. Frequency, severity and duration of psychiatric symptoms.

b\. Length of remissions, to include capacity for adjustment during
periods of

remissions.

c\. Extent of time lost from work over the past 12 month period and
social

impairment. If employed, identify current occupation and length of time
at this

job. If unemployed, note in [complaints]{.underline} whether veteran
contends it is due to

the effects of a mental disorder. Further indicate following
[**DIAGNOSIS**]{.smallcaps} what

factors, and objective findings support or rebut that contention.

d\. Treatments including statement on effectiveness and side effects
experienced.

3\. [Subjective Complaints]{.underline}:

a\. Describe fully.

C. **Examination (Objective Findings):**

Address each of the following and fully describe:

1\. Mental status exam to confirm or establish diagnosis in accordance
with DSM-IV.

2\. Additionally, to allow evaluation by the rating specialist, describe
and fully

explain the existence, frequency, and extent of the following signs and
symptoms, or

any others present, and relate how they interfere with employment and
social

functioning:

a\. Impairment of thought process or communication.

b\. Delusions, hallucinations and their persistence.

c\. Inappropriate behavior cited with examples.

d\. Suicidal or homicidal thoughts, ideations or plans or intent.

e\. Ability to maintain minimal personal hygiene and other basic
activities of daily

living.

f\. Orientation to person, place and time.

g\. Memory loss or impairment (both short and/or long term).

h\. Obsessive or ritualistic behavior which interferes with routine
activities

(describe with examples).

i\. Rate and flow of speech and note irrelevant, illogical, or obscure
speech

patterns and whether constant or intermittent.

j\. Panic attacks noting the severity, duration, frequency and effect on
independent

functioning and whether clinically observed or good evidence of prior
clinical or

equivalent observation.

k\. Depression, depressed mood or anxiety.

l\. Impaired impulse control and its effect on motivation or mood.

m\. Sleep impairment and describe extent it interferes with daytime
activities.

n\. Other symptoms and the extent to which they interfere with
activities.

D. **Diagnostic Tests:**

1\. Provide psychological testing if deemed necessary.

2\. If testing is requested, the results must be reported and considered
in arriving at the

diagnosis.

3\. Provide any specific evaluation information required by the rating
board or on

**BVA Remand** (in claims folder).

a\. **Competency:** State whether the veteran is capable of managing
his/her

benefit payments in the individual\'s own best interests (a physical
disability

which prevents the veteran from attending to financial matters in person
is not a

proper basis for a finding of incompetency unless the veteran is, by
reason of

that disability, incapable of directing someone else in handling the
individual\'s

financial affairs).

b\. **Other Opinion:** Furnish any other specific opinion requested by
the

rating board or BVA Remand furnishing the complete rationale and
citation of

medical texts or treatise supporting opinion, if medical literature
review was

undertaken. If the requested opinion is medically not ascertainable on
exam or

testing, please indicate **why.** If the requested opinion can not be
expressed

without resorting to speculation or making improbable assumptions say
so, and

explain why. If the opinion asks \"\...is it at least as likely as
not\...?\", fully

explain the clinical findings and rationale for the opinion.

4\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Provide:

1\. The Diagnosis must conform to DSM-IV and be supported by the
findings on the

examination report.

2\. If the diagnosis is changed, explain fully whether the new diagnosis
represents a

progression of the prior diagnosis or development of a new and separate
condition.

3\. If there are multiple mental disorders, delineate to the extent
possible the symptoms

associated with each and a discussion of relationship.

4\. Evaluation is based on the effects of the signs and symptoms on
occupational and

social functioning.

.

**NOTE:** VA is prohibited by statute from paying compensation for a
disability that is a result of the veteran\'s own **ALCOHOL OR DRUG
ABUSE**, whether based on direct service connection, secondary service
connection, or aggravation by a service-connected condition. Therefore,
when alcohol or drug abuse accompanies or is associated with another
mental disorder, separate, to the extent possible, the effects of the
alcohol or drug abuse from the effects of the other mental disorder(s).
If it is not possible to separate the effects, explain why.

F. **Global Assessment of Functioning (GAF):**

> **NOTE:** The complete multi-axial format as specified by DSM-IV may
> be required by BVA REMAND or specifically requested by the rating
> specialist. If so, include the GAF score and note whether it refers to
> current functioning. A BVA REMAND may also request, in addition to an
> overall GAF score, that a separate GAF score be provided for each
> mental disorder present when there are multiple Axis I or Axis II
> diagnoses and not all are service-connected. If separate GAF scores
> can be given, an explanation and discussion of the rationale is
> needed. If it is not possible, an explanation as to why not is needed.
> (See the above note pertaining to alcohol or drug abuse, the effects
> of which cannot be used to assess the effects of a service-connected
> condition.)

Signature: Date:

Compensation and Pension Examination

**EATING DISORDERS (Mental Disorders)**

Name: SSN:

Date of Exam: C-number:

Place of Exam

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

Comment on:

1\. [Past Medical History:]{.underline}

a\. Previous hospitalizations and outpatient care for parenteral
nutrition or tube

feeding.

b\. Medical and occupational history from the time between the last such
rating

examination and the present needs to be accounted for, UNLESS the
purpose

of this examination is to ESTABLISH service connection, then a complete

medical history since discharge from military service is required.

c\. Periods of incapacitation (during which bedrest and treatment by a
physician

are required due to the eating disorder). Describe the frequency and
duration.

d\. Current treatment, response, side effects.

2\. [Present Medical, Occupational and Social History]{.underline} -
over the past one year.

a\. History of onset of eating disorder.

b\. Its course, treatment, and current status to include symptoms.

c\. Extent of time lost from work over the past 12 month period and
social

impairment. If employed, identify current occupation and length of time
at this

job.

3\. [Subjective Complaints:]{.underline}

a\. Describe fully.

C. **Examination (Objective Findings):**

Address each of the following and fully describe:

1\. Mental status exam to confirm or establish diagnosis in accordance
with DSM-IV.

2\. Additionally, please provide this specific information: a. Current
weight.

b\. Expected minimum weight based on age, height, and body build.

c\. Obtain weight history.

3\. Additionally, to allow evaluation by the rating specialist, describe
and fully explain the

existence, frequency, and extent of the following signs and symptoms and
relate how

they interfere with employment:

a\. Binge eating.

b\. Self-induced vomiting or other measure to prevent weight gain when
weight is

already below expected minimum normal weight.

D. **Diagnostic Tests** (including psychological testing if deemed
necessary):

1\. Provide specific evaluation information required by the rating board
or on a BVA

Remand. Diagnostic Tests (See the examination request remarks for
specifics.):

a\. **Competency:** State whether the veteran is capable of managing his
or her

benefit payments in the individual\'s own best interests (a physical
disability

which prevents the veteran from attending to financial matters in person
is not a

proper basis for a finding of incompetency unless the veteran is, by
reason of

that disability, incapable of directing someone else in handling the
individual\'s

financial affairs).

b\. **Other Opinion:** Furnish any other specific opinion requested by
the

rating board or BVA Remand furnishing the complete rationale and
citation

of medical texts or treatise supporting opinion, if medical literature
review was

undertaken. If the requested opinion is medically not ascertainable on
exam or

testing please state why. If the requested opinion can not be expressed

without resorting to speculation or making improbable assumptions say
so, and

explain why. If the opinion asks \"\...is it at least as likely as
not\...\", fully explain

the clinical findings and rationale for the opinion.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

Signature: Date:

Compensation and Pension Examination

**DENTAL AND ORAL**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

[Narrative:]{.underline} Regional Office action is required for all
dental treatment based on combat wounds, service trauma, prisoner of war
or extracted teeth under 38 CFR 17.123.

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe:

1\. Describe extent of functional impairment due to loss of motion and
masticatory

function loss.

2\. Describe the extent and number of missing teeth and whether the
masticatory surface

can be replaced by a prosthesis.

3\. If limitation of inter-incisal range of motion, provide actual range
in mm (i.e., 0-Xmm)

and also provide lateral excursion (i.e., 0-Xmm).

4\. Describe the extent of any bone loss of mandible, maxilla, or hard
palate. For hard

palate and maxilla bone loss, state whether replaceable by prosthesis.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. X-ray to determine extent of bone tissue loss.

2\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. Give etiology where there is loss of teeth due to loss of substance
of body of maxilla or mandible.

Signature: Date:

Compensation and Pension Examination

**COLD INJURY PROTOCOL EXAMINATION**

Name: SSN:

Date of Exam: C-number:

Place of Exam:

**Narration:** Veterans during World War II, the Korean War, and in
smaller numbers during other campaigns, have suffered cold injuries,
including frostbite (freezing cold injury or FCI) and immersion foot
(nonfreezing cold injury or NCI). Documentation of such injuries may be
lacking because of battlefield conditions. A number of long-term and
delayed sequelae to cold injuries are recognized, including peripheral
neuropathy, skin cancer in frostbite scars, and arthritis in involved
limbs.

**Review Examination:** Any veteran examined for residuals of cold
injury should undergo a cold injury protocol examination **if** it has
not already been carried out. If the veteran has already had a cold
injury protocol examination, only an interval history is required, and
the extent of the examination, laboratory tests performed, etc., will be
determined by the examiner based on the history, and as requested.

A. **Review of Medical Records:**

B. **Medical History (Subjective Complaints):**

**[History of Cold Injury:]{.underline}** If the cold injury protocol
form has been filled out by the veteran, most details about the
circumstances of the acute cold injury and its subsequent course will be
recorded. Review for any needed expansion or clarification by the
veteran. If the protocol history form has not been completed, obtain the
following history and comment on each:

1\. Description of the circumstances of the cold injury.

2\. Parts of the body affected.

3\. Signs and symptoms - at time of acute injury.

4\. The type of treatment and where it was administered.

*5.* Any treatment since service - where and what type.

6\. Current symptoms - specifically inquire about:

a\. Amputations or other tissue loss.

b\. Cold sensitization.

c\. Raynaud\'s phenomenon.

d\. Hyperhidrosis.

e\. Paresthesias, numbness.

f\. Chronic pain resembling causalgia or reflex sympathetic dystrophy.

g\. Recurrent fungal infections.

h\. Breakdown or ulceration of frostbite scars.

i\. Disturbances of nail growth.

j\. Skin cancer in chronic ulcers or scars.

k\. Arthritis or joint stiffness, including limitation of motion of
affected areas.

l\. Edema.

m\. Changes in skin color.

n\. Skin thickening or thinning.

o\. Any sleep disturbance due to associated symptoms.

p\. Cold feeling (relationship to season or not).

q\. Numbness, tingling, burning.

r\. Excess sweating.

s\. Pain - location, intensity, constancy, precipitating factors (cold,
walking,

standing, night pain); type (sharp burning, etc.).

7\. Current treatment, including nonmedical measures taken - moving to
warmer climate,

wearing multiple pairs of socks, etc.

**[Other Medical History:]{.underline}**

1\. Major illnesses, surgery, current medical conditions and their
treatment, including

diabetes mellitus or hypertension.

2\. Smoking history, other risk factors for vascular disease, history of
skin cancer.

C. **Physical Examination (Objective Findings):**

Address each of the following and fully describe current findings:

1\. **General:** Carriage, gait, posture.

2\. **Skin:**

a\. Color.

b\. Edema.

c\. Temperature.

d\. Atrophy.

e\. Dry or moist.

f\. Texture.

g\. Ulceration.

h\. Hair growth.

i\. Evidence of fungus or other infection.

3\. **Scars:**

a\. Location.

b\. Length.

c\. Width.

d\. Color.

e\. Tenderness.

f\. Raised or depressed.

g\. If of head or neck, any disfigurement.

4\. **Nails:**

a\. All or part missing

b\. Evidence of fungus infection

c\. Deformed or atrophic

5\. **Neurological:**

a\. Reflexes.

b\. Sensory - subjective complaints of pain, numbness, etc., Objective
sensory

changes - pinprick, touch.

c\. Motor - weakness, atrophy.

6\. **Orthopedic:**

a\. Pain or stiffness of any joints affected by cold injury.

b\. Deformity or swelling of any joints.

c\. Measure range of motion of all affected joints.

d\. Strength of ligaments in affected areas.

e\. Pes planus.

f\. Callus.

g\. Pain on manipulation of joints.

h\. Loss of tissue of digits or other affected parts.

7\. **Vascular:**

a\. Status of peripheral pulses.

b\. Doppler study to confirm vascular compromise, if indicated.

c\. Evidence of vascular insufficiency - edema, hair loss, shiny
atrophic skin, etc.

d\. Blood pressure in arms and legs (is ratio normal?).

e\. Evidence of Raynaud\'s phenomenon.

D. **Diagnostic and Clinical Tests:**

Provide:

1\. X-rays of affected areas of extremities if never done or if not done
in past five years.

2\. Doppler study of blood vessels, if indicated.

3\. Nerve conduction studies, if indicated.

4\. Biopsy of any area suspicious for malignancy.

5\. Scrapings to confirm fungus infection.

6\. Include results of all diagnostic and clinical tests conducted in
the examination report.

E. **Diagnosis:**

1\. List each diagnosis and state whether related to cold injury (if
that can be determined).

2\. Specialty exams that might be needed:

a\. Neurology.

b\. Podiatry.

c\. Dermatology.

d\. Rheumatology.

e\. Others as needed.

Signature: Date:

**HELPFUL HINTS FROM THE SEVEN STEPS TEAM:**

There may be prescriptive language that appears to make a contract
detail-oriented and not performance-based; however, agencies may have
minimum requirements that must be met, such as the specific worksheets
that must be documented for the VA Medical Disability Exams. We also see
this when agencies are trying to leverage what has already been
purchased that could be a component of the proposed solution. For
example, if an agency knows it must use Microsoft software because all
the licenses have already been purchased, then that would be something
the agency would have to disclose when outlining the requirements. As
long as the contract file documents why minimum requirements are
contained in the contract and they are based on something that has a
reasonable rationale or is mandatory, the contract can still be
considered performance based.