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          PHYSICIAN'S STATEMENT FOR DIABETES

           

           

          Veteran's Name:

           

           

           

           

           

           

           

           

           

          Veterans SSN:

           

           

           

           

           

           

           

           

           

          VA Claim Number:

           

           

           

           

          Diagnosis:

           

           

           

           

           

          (Physician's Initials)

          The veteran has been diagnosed with Diabetes Mellitus, Type II (adult onset).

           

           

           

           

           

          Evaluation: Please check only one applicable statement

          The veteran's diabetes mellitus is manageable by restricted diet ONLY.

           

           

           

           

           

          The veteran's diabetes mellitus requires insulin and restricted diet, or oral hypoglycemic agent and restricted diet.

           

           

           

           

           

          The veteran's diabetes mellitus requires insulin, restricted diet, AND regulation of activities.

          (Please describe regulation of activities in the Remarks section below).

          The veteran's diabetes mellitus requires insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalization per year or twice a month visits to a diabetic care provider.

          Complications:

           

           

           

           

          The veteran currently has NO complication that are directly due to diabetes mellitus.

           

           

           

           

           

          The veteran has the following complication that are directly due to diabetes mellitus, or is likely to be caused in part and/or aggravated by the diabetes mellitus.

           

           

          Visual

          Cardiovascular

           

           

           

          Neurological

          Renal

           

           

           

          Other:

           

           

           

           

           

          Remarks:

           

           

           

           

           

           

           

           

           

          PHYSICIAN'S SIGNTURE

           

          DATE

           

           

           

           

           

           

           

           

          PHYSICIAN'S PRINTED NAME

           

          PHYSICIAN'S ADDRESS & PHONE #

          Please return completed, SIGNED form to:

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