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ICD code: _____ Date of amputation: _____ Amputation #2: _____ ICD code: _____ ... Is the marked inward displacement and severe spasm of the Achilles tendon improved by orthopedic. shoes or appliances? ... Does the Veteran have a history of rupture of the diaphragm with herniation? Yes No . If yes, also complete Hiatal Hernia Questionnaire. ... ................
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