Veterans Affairs banner with U.S. FlagVeterans Affairs banner with U.S. Flag

Disability Examination Worksheets

Genitourinary Examination

Genitourinary


Name: SSN:
Date of Exam: C-number:
Place of Exam:


A. Review of Medical Records:

B. Medical History (Subjective Complaints):
Comment on:
  1. For renal dysfunctions, state whether each of the following symptoms are present or absent: lethargy, weakness, anorexia and weight loss or gain.
  2. Urinary flow: frequency (day or night, indicate voiding intervals during the day and number of times during the night), hesitancy, stream, dysuria.
  3. Incontinence - if present, describe required frequency of changing absorbent material/day and/or whether or not an appliance is needed.
  4. Provide details of any history of:
  1. Surgery on any part of the urinary tract. Residuals? Impotence?
  2. Recurrent urinary tract infections.
  3. Renal colic or bladder stones.
  4. Acute nephritis.
  5. Hospitalization for urinary tract disease, if so, diagnosis, how many in the past year?
  6. Neoplasm-diagnosis, date of diagnosis, benign or malignant type and date of last treatment.
5. Treatments.
  1. Is catheterization needed? Intermittent or continuous?
  2. Dilations- Frequency of dilations?
  3. Drainage procedures.
  4. Diet therapy - specify.
  5. Medications.
  6. Frequency per year of invasive and noninvasive procedures. Type of procedure.
6. Describe the effects of the condition(s) on the veteran's usual occupation and daily activities.
7. If on dialysis, how often?
8. For Males-Erectile dysfunction
Comment on:
  1. Presence or absence.
  2. Trauma/surgery affecting penis/testicles (e.g. vasectomy?)
  3. Local and/or systemic diseases affecting sexual function.
  1. Endocrine.
  2. Neurologic.
  3. Infections.
  4. Vascular.
  5. Psychological.
    d. Symptoms: Vaginal penetration with ejaculation possible? Is ejaculation retrograde?

    e. Past treatment:
  1. Medications, injections, implants, pump, counseling.
  2. Effective in allowing intercourse.
C. Physical Examination (Objective Findings):
Address each of the following, as appropriate, to the condition being examined and fully describe current findings:
  1. Blood pressure, describe edema, to include persistence.
  1. Cardiovascular examination, if indicated
  1. For males: inspection and palpation of penis, testicles, epididymis, and spermatic cord. If there is penis deformity, state whether there is loss of erectile power. Inspection of anus and digital exam of rectal walls, prostate, and seminal vesicles.
  2. Sensation and reflexes.
  3. Peripheral pulses.
  4. Fistula.
  5. Testicular atrophy - size and consistency.
  6. Any other residuals of genitourinary disease, including post-treatment residuals of malignancy.
D. Diagnostic and Clinical Tests:
  1. CBC.
  2. UA. including microscopic analysis to assess for presence or absence of hyaline casts, granular casts, and red blood cells
  3. Creatinine, BUN, minimum, if renal dysfunction is an issue.
  4. Uroflowmetry, if indicated.
  5. Measurement of post-void residual, if indicated.
  6. Semen analysis, including sperm count and interpretation of results, if applicable.
  7. Endocrine evaluation (glucose, TSH, testosterone, LH, FSH, prolactin), if applicable.
  8. Psychiatric evaluation, if applicable.
  9. Include results of all diagnostic and clinical tests conducted in the examination report.
E. Diagnosis:

Signature: it says not signed Date: it says not dated


Compensation and Pension | GI Bill | Vocational Rehabilitation | Home Loans | Life Insurance
Regional Office Homepages | Manuals & Regulations | Reports & Surveys
Survivors' Benefits | If You Owe VA Money
GovBenefits.gov | USA Services