HEMATOLOGIC AND LYMPHATIC CONDITIONS ... - …

1 HEMATOLOGIC and LYMPHATIC CONDITIONS Disability Benefits Questionnaire Released January 2022 Updated on March 31, 2020 ~v20_1 Page 1 HEMATOLOGIC AND LYMPHATIC CONDITIONS , INCLUDING LEUKEMIA DISABILITY BENEFITS QUESTIONNAIRENAME OF PATIENT/VETERANPATIENT/VETERAN'S SOCIAL SECURITY NUMBERNote - The Veteran is applying to the Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire as part of their evaluation in processing the Veteran's claim. VA may obtain additional medical information, including an examination, if necessary, to complete VA's review of the veteran's application.

2 VA reserves the right to confirm the authenticity of ALL questionnaires completed by providers. It is intended that this questionnaire will be completed by the Veteran's - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. Are you completing this Disability Benefits Questionnaire at the request of:Veteran/ClaimantOther: please describeAre you a VA Healthcare provider?Is the Veteran regularly seen as a patient in your clinic? YesNoYesNoWas the Veteran examined in person?

3 YesNoIf no, how was the examination conducted?Please identify the evidence reviewed ( service treatment records, VA treatment records, private treatment records) and the date range. Evidence reviewed:EVIDENCE REVIEWNo records were reviewedRecords reviewedHematologic and LYMPHATIC CONDITIONS Disability Benefits Questionnaire Released January 2022 Updated on March 31, 2020 ~v20_1 Page 21B. IF THERE ARE ADDITIONAL OR PRIOR DIAGNOSES THAT PERTAIN TO HEMATOLOGIC OR LYMPHATIC CONDITIONS , LIST USING ABOVE FORMAT:SECTION I - DIAGNOSIS1A. CHECK THE CLAIMED HEMATOLOGICAL AND/OR LYMPHATIC CONDITION(S) THAT PERTAIN TO THIS DBQ: ICD CODE:Non-Hodgkin's lymphomaOther, specify DATE OF DIAGNOSIS: ICD CODE:Sickle cell anemia DATE OF DIAGNOSIS: ICD CODE:Polycythemia vera DATE OF DIAGNOSIS:Hodgkin's lymphoma ICD CODE: DATE OF DIAGNOSIS: ICD CODE:Anemia DATE OF DIAGNOSIS: ICD CODE:Immune thrombocytopenia DATE OF DIAGNOSIS: ICD CODE: ICD CODE: DATE OF DIAGNOSIS: DATE OF DIAGNOSIS: ICD CODE: DATE OF DIAGNOSIS:Solitary plasmacytoma ICD CODE: DATE OF DIAGNOSIS: DATE OF DIAGNOSIS.

4 ICD CODE:Myelodysplastic syndromeMultiple myeloma ICD CODE: DATE OF DIAGNOSIS:Chronic lymphocytic leukemia (CLL) ICD CODE: DATE OF DIAGNOSIS:Other diagnosis #2:Other diagnosis #3:Other diagnosis #1: ICD CODE:Chronic myelogenous leukemia (CML) (chronic myeloid leukemia or chronic granulocytic leukemia) DATE OF DIAGNOSIS: ICD CODE:Agranulocytosis, acquired DATE OF DIAGNOSIS:Leukemia ICD CODE:Hairy cell or other B-cell leukemia DATE OF DIAGNOSIS:Active diseaseTreatment phaseIndolent and non-contiguous phase of low grade NHLA plastic anemiaIron deficiency anemiaFolic acid deficiencyPernicious anemia or other Vitamin B12 deficiency anemiaAcquired hemolytic anemiaAL amyloidosis (primary amyloidosis)Adenitis, tuberculous (Also complete the Infectious Diseases (Other Than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire).

5 ActiveInactive ICD CODE:Essential thrombocythemia or primary myelofibrosis DATE OF DIAGNOSIS:NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the comments section. Date of diagnosis can be the date of evaluation if the clinician is making the initial diagnosis, or an approximate date determined through record review or reported history.

6 OtherOther DATE OF DIAGNOSIS: ICD CODE: DATE OF DIAGNOSIS: ICD CODE: DATE OF DIAGNOSIS: ICD CODE: DATE OF DIAGNOSIS: ICD CODE: DATE OF DIAGNOSIS: ICD CODE: DATE OF DIAGNOSIS: ICD CODE: DATE OF DIAGNOSIS: ICD CODE:Treatment phaseActive diseaseSplenectomyInjury to SpleenAre there complications such as systemic infections with encapsulated bacteria? NOYESIf Yes, complete SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS , SIGNS AND/OR SYMPTOMS. If checked, complete SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS , SIGNS AND/OR SYMPTOMS.

7 DATE OF DIAGNOSIS: ICD CODE: DATE OF DIAGNOSIS: ICD CODE: DATE OF DIAGNOSIS: ICD CODE: HEMATOLOGIC and LYMPHATIC CONDITIONS Disability Benefits Questionnaire Released January 2022 Updated on March 31, 2020 ~v20_1 Page 32B. IS continuous MEDICATION REQUIRED FOR CONTROL OF A HEMATOLOGIC OR LYMPHATIC CONDITION, INCLUDING ANEMIA OR THROMBOCYTOPENIA CAUSED BY TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC CONDITION?2A. DESCRIBE THE HISTORY (including cause (if known), onset and course) OF THE VETERAN'S CURRENT HEMATOLOGIC OR LYMPHATIC CONDITION(S) (brief summary):SECTION II - MEDICAL HISTORYIF YES, LIST ONLY THOSE MEDICATIONS REQUIRED FOR CONTROL OF THE VETERAN'S HEMATOLOGIC OR LYMPHATIC CONDITION, INCLUDING ANEMIA OR THROMBOCYTOPENIA CAUSED BY TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC CONDITION.

8 PROVIDE THE NAME OF THE MEDICATION AND THE CONDITION THE MEDICATION IS USED TO TREAT:YESNOACTIVENOT APPLICABLE2C. INDICATE THE STATUS OF THE PRIMARY HEMATOLOGIC OR LYMPHATIC CONDITION:REMISSIONSECTION III - TREATMENTT reatment completed; currently in watchful waiting statusNO; WATCHFUL WAITINGYESIF YES, INDICATE TYPE OF TREATMENT THE VETERAN IS CURRENTLY UNDERGOING OR HAS COMPLETED (Check all that apply):Transplant (specify type) Date of hospital admission and location:3A. HAS THE VETERAN COMPLETED ANY TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING ANY TREATMENT FOR ANY HEMATOLOGIC OR LYMPHATIC CONDITION, INCLUDING LEUKEMIA?

9 Date of hospital discharge after transplant:Peripheral blood stem cell transplant Bone marrow stem cell transplant Other (specify) If checked, provide: Other therapeutic procedureOther therapeutic treatmentIf checked, describe procedure:Surgery, if checked describe:Antineoplastic chemotherapyRadiation therapyDate of completion of treatment or anticipated date of completion:Date of completion of treatment or anticipated date of completion:Date of most recent procedure:Date of completion of treatment or anticipated date of completion:Date(s) of surgery:Date of most recent treatment:Date of most recent treatment:If checked, describe treatment:SECTION IV - ANEMIA AND THROMBOCYTOPENIA 4A.

10 DOES THE VETERAN HAVE ANEMIA OR THROMBOCYTOPENIA, INCLUDING THAT CAUSED BY TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC CONDITION?NOYESIF YES, COMPLETE THE FOLLOWING: HEMATOLOGIC and LYMPHATIC CONDITIONS Disability Benefits Questionnaire Released January 2022 Updated on March 31, 2020 ~v20_1 Page 4 SECTION IV - ANEMIA AND THROMBOCYTOPENIA (Continued)4D. IRON DEFICIENCY ANEMIAYESNO4C. APLASTIC ANEMIA:YESNO4B. DOES THE VETERAN HAVE ANEMIA (other than Sickle Cell Anemia) OR THROMBOCYTOPENIA?IF YES, PLEASE CHECK TYPE:IF YES, PROVIDE THE NAME OF THE OTHER HEMATOLOGIC OR LYMPHATIC CONDITION CAUSING THE SECONDARY ANEMIA:Infections recurring, on average, at least.