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Disability Examination Worksheets
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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):
1. Describe onset and course of disease, whether it is
intermittent or constant, and whether it is progressive.
2. Describe current treatment. Specify the medication(s)
used and dosage. State whether any is a corticosteroid
or other
immunosuppresive drug. State whether medications
used are systemic or
topical. Describe whether intensive
light therapy, UVB, PUVA, or electron
beam therapy are used.
3. For EACH treatment, report the frequency of use and
duration
of treatment during the past 12-month period.
4. Describe any side effects of treatment.
5. Describe local (skin) symptoms and any systemic
symptoms,
such as fever or weight loss.
6. For malignant neoplasms of skin, additionally describe
all treatment, including date and type of last treatment.
7. For benign neoplasms of skin, additionally describe any
impairment of function.
8. For urticaria, primary cutaneous vasculitis, and
erythema multiforme, additionally describe the number of
episodes during
the past 12-month period, whether the
episodes are debilitating, how they
are treated, and
whether they respond to treatment.
C. Physical Examination (Objective Findings):
1. For dermatitis, eczema, leishmaniasis, lupus,
dermatophytosis, bullous disorders, psoriasis, infections of the skin,
cutaneous manifestations of collagen vascular diseases, and papulosquamous
disorders, report extent of disease. Specify if any exposed areas (head, face,
neck, and hands) are affected. Provide the percent affected of exposed areas.
Provide the percent affected of the entire body.
2. If there is scarring or disfigurement, follow the
"Scars"
worksheet in addition to this one.
3. For acne or chloracne, describe whether the acne is
superficial (with comedones, papules, pustules, superficial
cysts) or deep
(with deep inflamed nodules and pus-filled
cysts), which areas of the body
are affected, and,
specifically, the PERCENT OF FACE AND NECK
affected.
4. For scarring alopecia, describe the PERCENT OF THE
SCALP
that is affected.
5. For alopecia areata, describe whether there is loss of
all
body hair or whether loss of hair is limited to the scalp
and
face.
6. For hyperhidrosis, state whether veteran is able to
handle
paper or tools after therapy, or is unable to handle paper
or
tools because of moisture and is unresponsive to therapy. D.
Diagnostic and Clinical Tests:
- Biopsy, scrapings if indicated.
- Include results of all diagnostic and clinical tests
conducted
in the examination report.
- With disfigurement or disfiguring scar of head, face, or
neck, submit COLOR PHOTOGRAPHS.
- Test for hypoproteinemia if examining for exfoliative
dermatitis (erythroderma).
E. Diagnosis:
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Date: |
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| Reviewed/Updated Date: December 15, 2008 |
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