The Dr. did not add my medication. Will that hurt my chance at getting 50%? What do you think?
LOCAL TITLE: C&P EXAMINATION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: MAR 31, 2016@11:30 ENTRY DATE: MAR 31, 2016@11:49:23
AUTHOR: REMBERT,FRANCIS M EXP COSIGNER: URGENCY: STATUS: COMPLETED Headaches (including Migraine Headaches) Disability Benefits Questionnaire Name of patient/Veteran:
SMITH, Maurice Is this DBQ being completed in conjunction with a VA 21-2507,
C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review ---------------
[X] VA e-folder (VBMS or Virtual VA) [X] CPRS
1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a headache condition?
[X] Yes [ ] No [X] Migraine including migraine variants ICD code: 000 Date of diagnosis: 1991
2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary): developed headaches which seem to be migraine b.
Does the Veteran's treatment plan include taking medication for the diagnosed condition? [ ] Yes [X] No
3. Symptoms ----------- a. Does the Veteran experience headache pain? [X] Yes [ ] No [X] Pulsating or throbbing head pain [X] Pain localized to one side of the head
b. Does the Veteran experience non-headache symptoms associated with headaches? (including symptoms associated with an aura prior to headache pain) [X] Yes [ ] No [X] Nausea [X] Vomiting [X] Sensitivity to light c. Indicate duration of typical head pain [X] 1-2 days d
. Indicate location of typical head pain [X] Right side of head
4. Prostrating attacks of headache pain --------------------------------------- a. Migraine / Non-Migraine-
Does the Veteran have characteristic prostrating attacks of migraine / non-migraine headache pain? [X] Yes [ ] No
If yes, indicate frequency, on average, of prostrating attacks over the last several months: [X] Once every month
Does the Veteran have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability? [X] Yes [ ] No 5
. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No
b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided.
6. Diagnostic testing --------------------- Are there any other significant diagnostic test findings and/or results? [ ] Yes [X]
No 7. Functional impact -------------------- Does the Veteran's headache condition impact his or her ability to work? [X] Yes [ ] No If yes, describe the impact of the Veteran's headache condition, providing one or more examples: says he cannot work when he has headaches 8. Remarks, if any: ------------------- No remarks provided. *********************************************************************