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: