IL 10-96-005
131
April 8, 1996
UNDER SECRETARY FOR HEALTH’S INFORMATION LETTER VA FUNDED EXAMINATION PROGRAM FOR THE SPOUSES AND CHILDREN OF PERSIAN GULF VETERANS
1. The VA Funded Examination Program for the Spouses and Children of Persian Gulf Veterans Program is being established to fulfill the legislative mandate in Public Law ( Pub. L.) 103-446, Section 107. Under this authority, Department of Veterans Affairs (VA) can provide examinations to any individual; who:
a. Is the spouse or child of a veteran, is listed in the Persian Gulf War Veterans Registry established under Pub. L. 102-585, Section 702; and is suffering from illness or disorder.
b. Is suffering from, or may have suffered from, an illness or disorder (including a birth defect, miscarriage, or stillbirth) which cannot be disassociated from the veteran’s service in the Southwest Asia theater of operations. NOTE: For areas included in the Southwest Asia theater of operations, see M-10, Part III, Chapter 2, paragraph 2.02a.
c. Has granted VA permission to include in the Registry relevant medical data from the evaluation.
2. The spending authority for this program will not exceed $2 million dollars; the program expires on September 30, 1996.
3. Registration for this program begins on April 1, 1996. Individuals wishing to participate can call toll free and register with a Persian Gulf War (PGW) Veterans, Helpline operator at 1-800-PGW-VETS. The first 4,500 eligible individuals calling the Helpline will be accepted for the program. Helpline personnel enter the required information into a computer database, which is forwarded to VHA Headquarters Environmental Agents Service. PGW veteran status and eligibility is determined by matching the data to the PGW Registry and deployment rosters. Information on participants whose eligibility has been confirmed will be forwarded to the Veterans Integrated Service Networks (VISN) offices on a weekly basis.
4. The coordinating VA medical center is responsible for establishing a contract with their university affiliated medical facility for the examinations of PGW spouses and children. Some weekend and evening appointments needs to be available, where possible. It is recommended that the contracts stipulate that payment will be made only after satisfactory completion and submission of all forms and code sheets to VA.
5. The coordinating medical centers need to ensure that each eligible participant is scheduled for an appointment by telephone, receives an invitation letter reaffirming the appointment time and location, and receives instructions to bring copies of all relevant previous medical records to the examination. A sample letter is provided in Attachment A. Within 48 hours prior to the appointment, the participant needs to receive a phone call from the medical center confirming the appointment. VA medical center coordinating facilities will verify the program participant’s relationship to the veteran by checking a marriage certificate for spouses, and birth certificate for children. Individuals who are not able to accept a scheduled examination within 45 days, or who do not report for their confirmed appointment will be reassigned to a waiting list.
6. The protocol for examination of PGW spouses involves a signed consent form, VA Form 10-21002a, Consent to Participate in VA’s Registry Examination Program for Spouses and Children of Persian Gulf veterans, (see Att. B), and VA Form 10-9009c, Persian Gulf Registry Code Sheet (Spouse or Child of Persian Gulf War Veteran), and VA Form 10-21002d, Adult Symptom Checklist (see Att. C). A physical examination is to be completed and recorded on the adult standardized exam form, VA Form 10-21002b, Funded PGW Spouses and Children Examination Program, (Attachment D). Diagnostic testing includes a complete blood count, blood chemistries (chem-20), urinalysis, and a Pap smear for women. Upon completion of the evaluation, VA Form 10-9009c, is to be completed and signed by the examining physician.
7. Protocol for the children of PGW veterans includes a detailed medical history including symptoms and a developmental history. A physical examination is to be completed and recorded on the juvenile standardized exam form, VA Form 10-21002c, Funded PGW Spouses and Children Examination Program (see Att. E). No routine diagnostic testing is required by the protocol. Any additional diagnostic testing, not exceeding a total of $400, is to be carried out only as deemed necessary by the examining physician, and after approval by the coordinating VA medical center. Upon completion of the evaluation, the Phase I code sheet is to be completed and signed by the examining physician. NOTE: All children are to be accompanied by a parent or guardian who can sign the required consent form.
8. A letter containing the results of the examination and any recommended medical follow-up is to be sent to each participant, or in the case of a child to the sponsoring veteran, by the contract physician. The letter includes a statement that the VA is not responsible for any medical follow-up or treatment of conditions diagnosed by the medical examination.
9. Diagnostic testing beyond that required by the protocols can be approved by the VA medical center PGW Registry physician up to, but not exceeding, a total cost (including the protocol exam and testing) of $400. If upon consultation with the contract physician, the VA medical center staff determine that additional diagnostic tests exceeding the $400.00 limit are necessary, the VA medical center forwards copies of the consultation, recommended test(s), and actual costs of the additional test(s) to the Environmental Agents Service (EAS). NOTE: Tests exceeding the $400 limit can not be authorized unless written EAS approval has been obtained.
10. After the VA medical center has received a complete examination package on the participating spouse or children, the PGW coordinator enters the International Classification of Diseases 9th Edition (ICD-9) codes for all symptoms and diagnoses and ensures that all other information is accurately and completely entered on the forms. A copy of the follow-up letter and all other examination forms and code sheets is incorporated into the PGW veterans VA consolidated health record. The original forms and code sheets are forwarded to the Austin Automation Center for entry into the PGW Spouses and Children Registry database.
11. A "Physicians’ Information Guide, Persian Gulf Veterans’ Illnesses" has been prepared by the Office of Public Health and Environmental Hazards. The physician’s guide includes current information concerning the symptoms and illnesses being reported in PGW veterans and their spouses and children. Topics covered includes clinical information available from VA and Department of Defense (DOD) PGW Registries, preliminary results of VA’s PGW mortality study, preliminary results of DOD’s PGW birth defects and hospitalization studies, and PGW-related publications from the scientific literature. Two copies of the guide have been provided to each coordinating VA medical center. All contract physicians participating in the examination program are required to familiarize themselves with the information included in the guide prior to examining participants.
12. A continuing medical education satellite video teleconference is planned for April 19, 1996 from 1:00 pm to 3:00 pm. This teleconference will include an overview of the current state of medical knowledge on the health of PGW spouses and children, additional information about the newly initiated VA PGW Spouses and Children Examination Program, and an interactive question and answer forum between VA medical center viewers and panelists.
13. Questions concerning this information letter or the PGW Spouses and Children Examination Program should be directed to the Office of Public Health and Environmental Hazards at (202) 565-4182 or (202) 565-4183. For administrative issues, ask for Donald Rosenblum or Oliver Parr; for medical questions, ask for Dr. Frances Murphy.
Signed by Dr. Garthwaite 4/8/96for
Kenneth W. Kizer, M.D., M.P.H
Under Secretary for Health
Attachments
DISTRIBUTION: CO E-mailed 4/9/96
FLD: VISN, MA, DO, OC, OCRO, and 200 - FAX 4/9/96
EX: Boxes 104, 88, 63, 60, 54, 52, 47 and 44 - FAX 4/9/96
(Date)
(Name/Address)
Dear------------------------:
Thank you for agreeing to participate in the recently established Department of Veterans Affairs (VA) examination program for the spouses and children of Persian Gulf War veterans. This program should allow us to learn more about the medical problems that Persian Gulf War families have been experiencing during the past few years. We very much appreciate your contribution to this program.
You have been scheduled for an examination on (day of week, date, 1996), at (time a.m./p.m.), at (location). Please call (contact person) at (telephone number) as soon as possible if, for any reason, you will be unable to keep this appointment.
Please bring the following items when you come for your appointment: copies of all relevant medical records, a marriage certificate if you are the spouse of a Persian Gulf War veteran, or a birth certificate for each child of the Persian Gulf veterans. We will call you at (telephone number) two days before your appointment to confirm it. Please contact us if there is a better number for us to reach you.
A follow-up letter describing the results of your examination and any recommendations will be sent to you within a few weeks of your examinations.
The health examination program for Persian Gulf veterans’ spouses and children was authorized by Public Law 103-446. However, we are not authorized to provide treatment for any medical problems that you may have. Prior to receiving the examination you will be asked to sign an informed consent form which explains the limitations of the program. You will not be examined until you sign the consent form.
Again, we thank you for your participation.
Sincerely yours,
(Name)
Coordinator, Persian Gulf Veterans’
Spouses and Children Program
VA-FUNDED PERSIAN GULF WAR VETERAN’S SPOUSES AND CHILDREN EXAMINATION PROGRAM CONSENT TO PARTICIPATE IN VA’s REGISTRY EXAMINATION PROGRAM FOR SPOUSES AND CHILDREN OF PERSIAN GULF VETERANS
I, _____________________, have requested participation in the Department of Veterans Affairs (VA) Persian Gulf War Veteran’s Spouses and Children Examination Program, authorized by Public Law 103-446, Section 107. I am the spouse/child (circle one) or ___________________, a Persian Gulf veteran.
I understand that if I choose to participate in this program, the Department of Veterans Affairs agrees to pay for a medical examination and diagnostic tests which are included in the Registry examination protocol for spouses and children. The diagnostic tests included in the protocol for adults involve drawing blood from my vein, undergoing a pelvic examination and Pap smear (women) and giving a urine specimen. Children will receive a medical examination but no blood or urine tests are required.
I give VA permission to enter the information obtained from my examination into a computer database, to study the results of my examination and analyze them along with the information of other program participants, and to report on the results of the examination program. VA will not identify me in any program report. My records will be kept confidential by VA. My decision to participate in this program will not affect, in any way, the treatment or benefits of my Persian Gulf veteran spouse/parent.
I understand that this program includes only the medical examination and testing
described in the preceding paragraphs. VA is not authorized to provide, and will not pay
for any follow-up care or treatment for medical problems or conditions identified during
the examination.
____________________________ ______________________________
Signature of participant Date
_____________________________ _______________________________
Signature of parent/guardian Date
for participant child under 18
ATTACHMENT C ADULT SYMPTOM CHECKLIST
1. Symptoms. Have any of the following symptoms been experienced during the past year. For the purpose of this examination, the severity of symptoms is defined as follows:
a. Mild. Just aware but not slowed down by symptoms, or sufficient to take non-prescription drugs to relieve the symptoms (aspirin, tums, etc.).
b. Severe. Sufficient to seek medical advice, take prescription drugs, lose work or limit routine activities.
2. Checklist
| a. In the past year,
have you had persistent or recurring problems with..?
NO
|
IF YES, PLEASE MARK ONE:
MILD SEVERE |
b. IF YES, did you first
experience this BEFORE (8/1/90), DURING (8/1/90), through 6/30/91), or AFTER Persian Gulf War (7/1/91)?
PLEASE MARK ONE:
BEFORE DURING AFTER |
c. Has this symptom been present in the last month?
NO YES |
|||
| 1. Any headaches O | O O | O O O | O O | |||
| 2. Any trouble with blurred vision, not O improved with glasses |
O O | O O O |
O O |
|||
| 3. Loss of hearing or
ringing in your ears O |
O O | O O O |
O O |
|||
| 4. Wheezing in your chest O |
O O | O O O |
O O |
|||
| 5. A runny nose or congestion of your O nose or sinuses |
O O | O O O |
O O |
|||
| 6. Problems with your
mouth, gums or teeth O |
O O | O O O |
O O |
|||
| 7. A sore throat, hoarse
voice or other throat O problems |
O O | O O O |
O O |
|||
| 8. Trouble swallowing O |
O O | O O O |
O O |
|||
| 9. Problems with swollen
glands (lymph nodes O in your neck and/or armpits |
O O | O O O |
O O |
|||
| 10. Problems with coughing O |
O O | O O O |
O O |
|||
|
a. In the past year, have you had persistent or recurring problems with..?
NO |
IF YES, PLEASE MARK ONE:
MILD SEVERE |
b. IF YES, did you first experience this BEFORE (8/1/90), DURING (8/1/90), through 6/30/91), or AFTER Persian Gulf War (7/1/91)?
PLEASE MARK ONE:
BEFORE DURING AFTER |
c. Has this symptom been present in the last month?
NO YES |
|||
| 11. Difficulty in breathing or O shortness of breath |
O O | O O O |
O O |
|||
| 12. Any tightness in your
chest O |
O O | O O O |
O O |
|||
| 13. An irregular heartbeat, including O heart pounding or racing |
O O | O O O |
O O |
|||
| 14. Back pain or spasms O |
O O | O O O |
O O |
|||
| 15. Swelling of both feet
or both ankles O |
O O | O O O |
O O |
|||
| 16. Generalized muscle
aching or cramps O |
O O | O O O |
O O |
|||
| 17. Joint aching or pain
O |
O O | O O O |
O O |
|||
| 18. Numbness or tingling sensation in hands or O feet |
O O | O O O |
O O |
|||
| 19. Swelling in any joints
O |
O O | O O O |
O O |
|||
| 20. Any tendency to bruise or bleed easily, O including nose bleeding |
O O | O O O |
O O |
|||
| 21. Skin rashes O |
O O | O O O |
O O |
|||
| 22. Any hair loss
O |
O O | O O O |
O O |
|||
| 23. A loss of balance or
dizziness O |
O O | O O O |
O O |
|||
| 24. A sudden loss of
strength O |
O O | O O O |
O O |
|||
| 25. Felt excessive fatigue
(not due to exercise) O |
O O | O O O |
O O |
|||
|
|
||||||
| a. In the past year,
have you had persistent or recurring problems with..?
NO
|
IF YES, PLEASE MARK ONE:
MILD SEVERE |
b. IF YES,
did you first experience this BEFORE (8/1/90), DURING (8/1/90), through 6/30/91), or AFTER Persian Gulf War (7/1/91)?
PLEASE MARK ONE:
BEFORE DURING AFTER |
c. Has this
symptom been present in the last month?
NO YES |
|||
| 26. Problems with
fatigue lasting more O than 24 hours after exertion |
O O |
O O O |
O O |
|||
| 27. Been nauseous
O |
O O |
O O O |
O O |
|||
| 28. Been vomiting
O |
O O |
O O O |
O O |
|||
| 29. Stomach or
abdominal pain O |
O O |
O O O |
O O |
|||
| 30. Reflux, heartburn,
or indigestion O |
O O |
O O O |
O O
|
|||
| 31. Diarrhea (loose
or watery stools) O |
O O |
O O O |
O O |
|||
| 32. Constipation
O |
O O |
O O O |
O O |
|||
| 33. Frequent or
painful urination O |
O O |
O O O |
O O |
|||
| 34. FEMALES ONLY:
Your partner ‘s O semen burns or leaves blisters on contact |
O O |
O O O |
O O |
|||
| 35. Painful sexual
intercourse O |
O O |
O O O |
O O |
|||
| 36. Impotence, or
other sexual problems O |
O O |
O O O |
O O |
|||
| 37. A fever or chills
O |
O O |
O O O |
O O |
|||
| 38. Problems with
sweating (not due to O exercise) |
O O |
O O O |
O O |
|||
| 39. Difficulty in
getting to sleep or staying O asleep |
O O |
O O O |
O O |
|||
| 40. Excessive
sleepiness during the daytime O |
O O |
O O O |
O O |
|||
|
|
|||
| a. In the past year, have you had persistent or recurring problems with..?
NO |
IF YES, PLEASE MARK ONE:
MILD SEVERE |
b. IF YES, did you first experience this BEFORE (8/1/90), DURING (8/1/90), through 6/30/91), or AFTER Persian Gulf War (7/1/91)?
PLEASE MARK ONE:
BEFORE DURING AFTER |
c. Has this symptom been present in the last month?
NO YES
|
| 41. Awaken feeling tired an worn out after a O full night of sleep |
O O | O O O |
O O |
| 42. Been anxious, irritable or upset O |
O O | O O O |
O O |
| 43. Been depressed or blue O |
O O | O O O |
O O |
| 44. Tremors/shaking O |
O O | O O O |
O O |
| 45. Wounds that are slow to heal O |
O O | O O O |
O O |
| 46. Difficulty with speech O |
O O | O O O |
O O |
| 47. Had difficulty in concentrating, O reasoning or memory loss |
O O |
O O O |
O O |
| 48. Compared to other people, do you consider O yourself unusually sensitive to everyday chemicals, like household cleaning supplies, paints, perfumes, soaps, garden sprays or new carpet? |
O O | O O O |
O O |
49. In the past 6 months have you lost more than 10 pounds, when you were not trying to lose weight?
O No O Yes
50. In the past 6 months, have you gained more than 10 pounds, when you were not trying to gain
weight?
O No O Yes
51. FEMALES ONLY: Have you had problems with heavy or painful menstruation in the past month?
O No O Yes ATTACHMENT D DEPARTMENT OF VETERANS AFFAIRS FUNDED PGW SPOUSES AND CHILDREN EXAMINATION PROGRAM SPOUSE’S PHYSICAL EXAMINATION
Examiner: _____________________
Location: ______________________
| Temperature = _____. ___deg F Blood pressure
= ___/__
|
||||
| Respirations = ____ per minute Pulse =
_____/minute
|
||||
| Weight = ______ lbs. Heights = __ft __ in.
|
||||
| (Circle appropriate responses) | ||||
| HEAD AND NECK |
||||
| EYES |
YES |
NO |
||
| pupils equal | 1 | 2 | ||
| pupils round | 1 | 2 | ||
| pupils reactive | 1 | 2 | ||
| accommodate | 1 | 2 | ||
| sclera | 1= normal |
2=icteric |
3=other |
|
| Nose: |
||||
| nasal ulcerations? | No | Yes | ||
| discharge? | No | Yes | ||
| abnormal erythema
|
No | Yes | ||
| Oropharynx: | ||||
| Teeth: Dentition: | 1=good | 2=fair | 3=poor | 4=edentulous |
| Gum: | 1=good | 2=fair | 3=poor | |
| Mucosa: | 1=Normal | 2=Abnormal | ||
| Neck |
||||
| Thyroid: | 1=Normal | 2=Enlarged | 3=Nodule | |
| Lymph Nodes | ||||
| Cervical | 1= Normal | 2=Abnormal | ||
| Supraclavicular | 1= Normal | 2=Abnormal | ||
| Axillary | 1= Normal | 2=Abnormal | ||
| Inguinal | 1= Normal | 2=Abnormal | ||
| Chest | Lung sounds |
1= Normal |
2=Abnormal |
|
| Cardiac: | Palpation Heart Sounds |
1=Normal 1= Normal |
2=Abnormal 2=Abnormal |
|
|
Name: _____________________
SSN: _______________________
|
||||
| ABDOMEN | Bowel Sounds |
1=Present |
2=Absent |
|
| Tenderness | 1= Normal | 2=Abnormal | ||
| Liver | 1= Normal | 2=Abnormal | ||
| Spleen | 1= Normal | 2=Abnormal | ||
| Mass | 1=No | 2=Yes | ||
| RECTAL |
|
|||
| Hemorrhoids | 1=Absent | 2=Present | ||
| Anal Fissures | 1=Absent | 2=Present | ||
| Stool hemocult | 1=Negative | 2=Positive | ||
| GENITOURINARY (Male) |
||||
| Penis lesions/ ulcerations |
1=Absent | 2=Present | ||
| Testicles | 1= Normal | 2=Abnormal | ||
| Varicocele | 1=Absent | 2=Present | ||
| GENITOURINARY (Female) |
||||
| Labia minora/majora | 1= Normal | 2=Abnormal | ||
| Urethra | 1= Normal | 2=Abnormal | ||
| Vagina | 1= Normal | 2=Abnormal | ||
| Cervix Uterus Ovaries |
1= Normal 1=Normal 1=Normal |
2=Abnormal 2=Abnormal 2=Abnormal |
||
| MUSCULOSKELETAL: (note any deformities, tenderness, swelling over joints/effusions, erythema/rash over joints, limitation of movements). |
||||
| Spine: | 1= Normal | 2=Abnormal | ||
| Shoulders: | 1= Normal | 2=Abnormal | ||
| Elbows | 1= Normal | 2=Abnormal | ||
| Wrists: | 1= Normal | 2=Abnormal | ||
| Hands: | 1= Normal | 2=Abnormal | ||
| Hips: | 1= Normal | 2=Abnormal | ||
| Knees: | 1= Normal | 2=Abnormal | ||
| Ankles: | 1= Normal | 2=Abnormal | ||
| Feet: | 1= Normal | 2=Abnormal | ||
| Cyanosis: | 1= Normal | 2=Abnormal | ||
| Clubbing: | 1= Normal | 2=Abnormal | ||
| EXTREMITIES | ||||
| Ankles | 1= Normal | 2=Edema | ||
| Rash | 1=Absent | 2=Present | ||
| SKIN (describe location and type of lesions)
|
||||
| Ulcerations | 1=Absent | 2=Present | ||
| Acne | 1=Absent | 2=Present | ||
| 3. NEUROLOGIC Cranial Nerves: |
Visual Fields: (confrontation testing) |
1= Normal |
2=Abnormal |
|
| Horizontal eye movements
|
1= Normal |
2=Abnormal |
||
| Facial movement & strength | 1=Normal | 2=Abnormal | ||
| Hearing (to normal voice): | 1=Normal | 2=Abnormal | ||
| Pharynx: elevate uvula | 1=Normal | 2=Abnormal | ||
| Trapezius & SCM Strenght | 1=Normal | 2=Abnormal | ||
| Muscle tone:
Muscle Strength |
1=Normal
1=Normal |
2=Hypotonic
2=Abnormal |
3=Hypertonic | |
| Able to rise from chair without using arms |
1=Can do |
2=Can’t do |
||
| Involuntary movements |
1=Absent | 2=Tremor | 3=Tic | |
| Sensory: |
||||
| Light touch in feet: | 1=Normal | 2=Abnormal | ||
| Pinprick in feet | 1=Normal | 2=Abnormal | ||
| Vibration in feet | 1=Normal | 2=Abnormal | ||
| Mental Status Examination --to be performed at end of interview
|
||||
| Mood | 1=Normal | 2=Abnormal | ||
| Speech | 1=Normal | 2=Abnormal | ||
| Memory: | 1=Normal | 2=Abnormal | ||
| Reflexes |
||||
| Biceps: | 1=Normal | 2=Absent | 3=Hyperflexia | |
| Triceps: | 1=Normal | 2=Absent | 3=Hyperflexia | |
| Patellar: | 1=Normal | 2=Absent | 3=Hyperflexia | |
| Ankle jerk: | 1=Normal | 2=Absent | 3=Hyperflexia | |
| Babinski: | 1=Absent | 2=Present | ||
| Coordination/Cerebellar: | ||||
| Finger-Nose-Finger: | 1=Normal | 2=Abnormal | ||
| Gait | 1=Normal | 2=Abnormal | ||
| Romberg: | 1=Absent | 2=Present | ||
| Heel, toe: | 1=Normal | 2=Abnormal | ||
4. Examiner comment (explain all abnormalities): NOTE: Attach additional pages as needed.
___________________________________________________________________________
___________________________________________________________________________
ATTACHMENT E DEPARTMENT OF VETERANS AFFAIRS FUNDED PGW SPOUSES AND CHILDREN EXAMINATION PROGRAM CHILD’S PHYSICAL EXAMINATION
Examiner: _____________________
Location: ______________________
| Temperature= _____. ___deg F Blood pressure =
___/__
|
||||
| Respirations = ____ per minute Pulse =
_____/minute
|
||||
| Weight = ______ lbs. _____ oz Heights = __ft
__ in.
|
||||
| Head Circumference:
___________________________
|
||||
| (Circle appropriate responses)
|
||||
| HEAD AND NECK |
||||
| EYES |
YES |
NO |
||
| pupils equal | 1 | 2 | ||
| pupils round | 1 | 2 | ||
| pupils reactive | 1 | 2 | ||
| accommodate | 1 | 2 | ||
| sclera | 1= normal |
2=icteric |
3=other |
|
| Nose: |
||||
| nasal ulcerations? | No | Yes | ||
| discharge? | No | Yes | ||
| erythema
|
No | Yes | ||
| Oropharynx: | ||||
| Teeth: Dentition: | 1=appropriate for age | 2=fair | 3=poor | |
| Gum: | 1=good | 2=fair | 3=poor | |
| Mucosa: | 1=Normal | 2=Abnormal | ||
| Neck |
||||
| Thyroid: | 1=Normal | 2=Enlarged | 3=Nodule | |
| Lymph Nodes | ||||
| Cervical | 1= Normal | 2=Abnormal | ||
| Supraclavicular | 1= Normal | 2=Abnormal | ||
| Axillary | 1= Normal | 2=Abnormal | ||
| Inguinal | 1= Normal | 2=Abnormal | ||
| Chest | Lung sounds |
1= Normal |
2=Abnormal |
|
| Cardiac: | Palpation Heart Sounds |
1=Normal 1= Normal |
2=Abnormal 2=Abnormal |
|
| Name:_______________________ SSN: ________________________ |
||||
| ABDOMEN | Bowel Sounds |
1=Present |
2=Absent |
|
| Tenderness | 1= Normal | 2=Abnormal | ||
| Liver | 1= Normal | 2=Abnormal | ||
| Spleen | 1= Normal | 2=Abnormal | ||
| Mass | 1=No | 2=Yes | ||
| GENITOURINARY (Male) |
||||
| Penis lesions/ ulcerations |
1=Absent | 2=Present | ||
| Testicles | 1= Normal | 2=Abnormal | ||
| GENITOURINARY (Female) |
||||
| Labia minora/majora | 1= Normal | 2=Abnormal | ||
| Urethra | 1= Normal | 2=Abnormal | ||
| MUSCULOSKELETAL: (note any deformities, tenderness, swelling over joints/effusions, erythema/rash over joints, limitation of movements). |
||||
| Spine: | 1= Normal | 2=Abnormal | ||
| Shoulders: | 1= Normal | 2=Abnormal | ||
| Elbows | 1= Normal | 2=Abnormal | ||
| Wrists: | 1= Normal | 2=Abnormal | ||
| Hands: | 1= Normal | 2=Abnormal | ||
| Hips: | 1= Normal | 2=Abnormal | ||
| Knees: | 1= Normal | 2=Abnormal | ||
| Ankles: | 1= Normal | 2=Abnormal | ||
| Feet: | 1= Normal | 2=Abnormal | ||
| Cyanosis: | 1= Normal | 2=Abnormal | ||
| Clubbing: | 1= Normal | 2=Abnormal | ||
| EXTREMITIES | ||||
| Ankles | 1= Normal | 2=Edema | ||
| Rash | 1=Absent | 2=Present | ||
| SKIN (describe location and type of lesions)
|
||||
| Ulcerations | 1=Absent | 2=Present | ||
| Acne | 1=Absent | 2=Present | ||
|
3.
|
||||
| NEUROLOGIC (Age -
appropriate)
Developmental Milestones
Cranial Nerves: Visual Fields: (confrontation testing) |
1= Normal
1=Normal |
2=Abnormal
2=Abnormal |
||
| Horizontal eye movements
|
1= Normal | 2=Abnormal | ||
| Pupillary size: | 1=Normal | 2=Miotic | 3=Dilated | 4=Irregular |
| Facial movement & strength | 1=Normal | 2=Abnormal | ||
| Hearing (to normal voice): | 1=Normal | 2=Abnormal | ||
| Pharynx: elevate uvula | 1=Normal | 2=Abnormal | ||
| Muscle tone: | 1=Normal | 2=Hypotonic | 3=Hypertonic | |
| Able to rise from chair without using arms |
1=Can do |
2=Can’t do |
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| Involuntary movements |
1=Absent |
2=Present |
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| Sensory: |
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| Light touch in feet: | 1=Normal | 2=Abnormal | ||
| Pinprick in feet | 1=Normal | 2=Abnormal | ||
| Vibration in feet | 1=Normal | 2=Abnormal | ||
| Mental Status Examination --to be performed at end of interview
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| Mood | 1=Normal | 2=Abnormal | ||
| Speech | 1=Normal | 2=Abnormal | ||
| Reflexes |
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| Biceps: | 1=Normal | 2=Absent | 3=Hyperflexia | |
| Triceps: | 1=Normal | 2=Absent | 3=Hyperflexia | |
| Patellar: | 1=Normal | 2=Absent | 3=Hyperflexia | |
| Ankle jerk: | 1=Normal | 2=Absent | 3=Hyperflexia | |
| Babinski: | 1=Absent | 2=Present | ||
| Coordination/Cerebellar: | ||||
| Finger-Nose-Finger: | 1=Normal | 2=Abnormal | ||
| Gait | 1=Normal | 2=Abnormal | ||
| Romberg: | 1=Absent | 2=Present | ||
| Heel, toe: | 1=Normal | 2=Abnormal | ||
4. Examiner comment (explain all abnormalities): NOTE: Attach additional pages as needed.
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