DVBCQAL2 ;;ALB-CIOFO/ECF - AMYOTROPHIC LATERAL SCLEROSIS (ALS) QUESTIONNAIRE ; 5/15/2011
;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
;
TXT ;
;;
;; Your patient is applying to the U. S. Department of Veterans Affairs
;; (VA) for disability benefits. VA will consider the information you
;; provide on this questionnaire as part of their evaluation in processing
;; the Veteran's claim.
;;
;; 1. Diagnosis
;;
;; Does the Veteran now have or has he/she ever been diagnosed with Amyotrophic
;; Lateral Sclerosis (ALS)?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to ALS:
;;
;; Diagnosis #1: ______________________________
;; ICD code: __________________________________
;; Date of diagnosis: _________________________
;;
;; Diagnosis #2: ______________________________
;; ICD code: __________________________________
;; Date of diagnosis: _________________________
;;
;; Diagnosis #3: ______________________________
;; ICD code: __________________________________
;; Date of diagnosis: _________________________
;;
;; If there are additional diagnoses that pertain to ALS, list using above
;; format: ____________________________________________________________________
;;
;; 2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's ALS
;; (brief summary):
;;
;; ____________________________________________________________________________
;;
;; b. Dominant hand
;;
;; ___ Right ___ Left ___ Ambidextrous
;;
;; 3. Conditions, signs and symptoms due to ALS
;;
;; a. Does the Veteran have any muscle weakness in the upper and/or lower
;; extremities attributable to ALS?
;; ___ Yes ___ No
;; If yes, report under strength testing in neurologic exam section.
;;^TOF^
;; b. Does the Veteran have any pharynx and/or larynx and/or swallowing
;; conditions attributable to ALS?
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ____ Constant inability to communicate by speech
;; ____ Speech not intelligible or individual is aphonic
;; ____ Paralysis of soft palate with swallowing difficulty (nasal
;; regurgitation) and speech impairment
;; ____ Hoarseness
;; ____ Mild swallowing difficulties
;; ____ Moderate swallowing difficulties
;; ____ Severe swallowing difficulties, permitting passage of liquids only
;; ____ Requires feeding tube due to swallowing difficulties
;; ____ Other, describe: ____________________________________________________
;;
;; c. Does the Veteran have any respiratory conditions attributable to ALS?
;; ___ Yes ___ No
;;
;; If yes, provide PFT results under 'Diagnostic testing' section.
;;
;; d. Does the Veteran have signs and/or symptoms of sleep apnea or sleep
;; apnea-like condition attributable to ALS?
;;
;; NOTE: If signs and/or symptoms of sleep apnea or sleep apnea-like condition
;; are due ALS, these symptoms are due to weakness in the palatal, pharyngeal,
;; laryngeal, and/or respiratory musculature. A sleep study is not indicated to
;; report symptoms of sleep apnea or sleep apnea-like conditions that are
;; attributable to ALS.
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ___ Persistent daytime hypersomnolence
;; ___ Requires use of breathing assistance device such as continuous
;; airway pressure (CPAP) machine
;; ___ Chronic respiratory failure with carbon dioxide retention or cor
;; pulmonale
;; ___ Requires tracheostomy
;;^TOF^
;; e. Does the Veteran have any bowel impairment attributable to ALS?
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ____ Slight impairment of sphincter control, without leakage
;; ____ Constant slight impairment of sphincter control, or occasional
;; moderate leakage
;; ____ Occasional involuntary bowel movements, necessitating wearing of
;; a pad
;; ____ Extensive leakage and fairly frequent involuntary bowel movements
;; ____ Total loss of bowel sphincter control
;; ____ Chronic constipation
;; ____ Other bowel impairment (describe): _________________________________
;;
;; f. Does the Veteran have voiding dysfunction causing urine leakage
;; attributable to ALS?
;; ___ Yes ___ No
;;
;; If yes, please check one:
;; ____ Does not require/does not use absorbent material
;; ____ Requires absorbent material that is changed less than 2 times per day
;; ____ Requires absorbent material that is changed 2 to 4 times per day
;; ____ Requires absorbent material that is changed more than 4 times per day
;;
;; g. Does the Veteran have voiding dysfunction causing signs and/or symptoms of
;; urinary frequency attributable to ALS?
;; ___ Yes ___ No
;;
;; If yes, check all that apply:
;; ____ Daytime voiding interval between 2 and 3 hours
;; ____ Daytime voiding interval between 1 and 2 hours
;; ____ Daytime voiding interval less than 1 hour
;; ____ Nighttime awakening to void 2 times
;; ____ Nighttime awakening to void 3 to 4 times
;; ____ Nighttime awakening to void 5 or more times
;;^TOF^
;; h. Does the Veteran have voiding dysfunction causing findings, signs and/or
;; symptoms of obstructed voiding attributable to ALS?
;; ___ Yes ___ No
;;
;; If yes, check all signs and symptoms that apply:
;; ____ Hesitancy
;; If checked, is hesitancy marked?
;; ___ Yes ___ No
;; ____ Slow or weak stream
;; If checked, is stream markedly slow or weak?
;; ___ Yes ___ No
;; ____ Decreased force of stream
;; If checked, is force of stream markedly decreased?
;; ___ Yes ___ No
;; ____ Stricture disease requiring dilatation 1 to 2 times per year
;; ____ Stricture disease requiring periodic dilatation every 2 to 3 months
;; ____ Recurrent urinary tract infections secondary to obstruction
;; ____ Uroflowmetry peak flow rate less than 10 cc/sec
;; ____ Post void residuals greater than 150 cc
;; ____ Urinary retention requiring intermittent or continuous catheterization
;;
;; i. Does the Veteran have voiding dysfunction requiring the use of an
;; appliance attributable to ALS?
;; ___ Yes ___ No
;;
;; If yes, describe appliance: ________________________________________________
;;
;; j. Does the Veteran have a history of recurrent symptomatic urinary tract
;; infections attributable to ALS?
;; ___ Yes ___ No
;;
;; If yes, check all treatments that apply:
;; ____ No treatment
;; ____ Long-term drug therapy
;; If checked, list medications used for urinary tract infection and
;; indicate dates for courses of treatment over the past 12 months:
;; _______________________________________________________________________
;; ____ Hospitalization
;; If checked, indicate frequency of hospitalization:
;; ____ 1 or 2 per year
;; ____ More than 2 per year
;; ____ Drainage
;; If checked, indicate dates when drainage performed over past 12
;; months: _______________________________________________________________
;; ____ Other management/treatment not listed above
;; Description of management/treatment including dates of treatment:
;; _______________________________________________________________________
;;^TOF^
;; k. Does the Veteran (if male) have erectile dysfunction?
;; ___ Yes ___ No
;; If yes, is the erectile dysfunction as likely as not (at least a 50%
;; probability) attributable to ALS?
;; ___ Yes ___ No
;; If no, provide the etiology of the erectile dysfunction: _____________
;;
;; ______________________________________________________________________
;;
;; If yes, is the Veteran able to achieve an erection (without medication)
;; sufficient for penetration and ejaculation?
;; ___ Yes ___ No
;; If no, is the Veteran able to achieve an erection (with medication)
;; sufficient for penetration and ejaculation?
;; ___ Yes ___ No
;;
;; 4. Neurologic exam
;;
;; a. Speech
;; ___ Normal ___ Abnormal
;; If speech is abnormal, describe: ___________________________________________
;;
;; b. Gait
;; ___ Normal ___ Abnormal, describe: _________________________________________
;; If gait is abnormal, and the Veteran has more than one medical condition
;; contributing to the abnormal gait, identify the conditions and describe each
;; condition's contribution to the abnormal gait: _____________________________
;;
;; c. Strength
;; Rate strength according to the following scale:
;; 0/5 No muscle movement
;; 1/5 Visible muscle movement, but no joint movement
;; 2/5 No movement against gravity
;; 3/5 No movement against resistance
;; 4/5 Less than normal strength
;; 5/5 Normal strength
;;
;; ___ All normal
;;
;; Elbow flexion: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Elbow extension: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Wrist flexion: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Wrist extension: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;;^TOF^
;; Grip: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Pinch (thumb to index finger):
;; Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Knee extension: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Ankle plantar flexion:
;; Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Ankle dorsiflexion:
;; Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
;;
;; d. Deep tendon reflexes (DTRs)
;; Rate reflexes according to the following scale:
;; 0 Absent
;; 1+ Decreased
;; 2+ Normal
;; 3+ Increased without clonus
;; 4+ Increased with clonus
;;
;; ___ All normal
;;
;; Biceps: Right: __0 __1+ __2+ __3+ __4+
;; Left: __0 __1+ __2+ __3+ __4+
;; Triceps: Right: __0 __1+ __2+ __3+ __4+
;; Left: __0 __1+ __2+ __3+ __4+
;; Brachioradialis: Right: __0 __1+ __2+ __3+ __4+
;; Left: __0 __1+ __2+ __3+ __4+
;; Knee: Right: __0 __1+ __2+ __3+ __4+
;; Left: __0 __1+ __2+ __3+ __4+
;; Ankle: Right: __0 __1+ __2+ __3+ __4+
;; Left: __0 __1+ __2+ __3+ __4+
;;
;; e. Plantar (Babinski) reflex
;;
;; Right: ___ plantar flexion (normal, or negative Babinski)
;; ___ dorsiflexion (abnormal, or positive Babinski)
;; Left: ___ plantar flexion (normal, or negative Babinski)
;; ___ dorsiflexion (abnormal, or positive Babinski)
;;
;; f. Does the Veteran have muscle atrophy attributable to ALS?
;; ___ Yes ___ No
;;
;; If muscle atrophy is present, indicate location: ___________________________
;; When possible, provide difference measured in cm between normal and
;; atrophied side, measured at maximum muscle bulk: _____ cm.
;;^TOF^
;; g. Summary of muscle weakness in the upper and/or lower extremities
;; attributable to ALS (check all that apply):
;;
;; Right upper extremity muscle weakness:
;; ___ None __ Mild __ Moderate __ Severe
;; ___ With atrophy __ Complete (no remaining function)
;;
;; Left upper extremity muscle weakness:
;; ___ None __ Mild __ Moderate __ Severe
;; ___ With atrophy __ Complete (no remaining function)
;;
;; Right lower extremity muscle weakness:
;; ___ None __ Mild __ Moderate __ Severe
;; ___ With atrophy __ Complete (no remaining function)
;;
;; Left lower extremity muscle weakness:
;; ___ None __ Mild __ Moderate __ Severe
;; ___ With atrophy __ Complete (no remaining function)
;;
;; NOTE: If the Veteran has more than one medical condition contributing to the
;; muscle weakness, identify the condition(s) and describe each condition's
;; contribution to the muscle weakness: _______________________________________
;;
;; 5. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;;
;; a. Does the Veteran have any scars (surgical or otherwise) related to any
;; conditions or to the treatment of any conditions listed in the Diagnosis
;; section above?
;; ___ Yes ___ No
;; If yes, are any of the scars painful and/or unstable, or is the total area
;; of all related scars greater than 39 square cm (6 square inches)?
;; ___ Yes ___ No
;; If yes, also complete a Scars Questionnaire.
;;
;; b. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs or symptoms related to ALS?
;; ___ Yes ___ No
;;
;; If yes, describe (brief summary): __________________________________________
;;
;; 6. Mental health manifestations due to ALS or its treatment
;;
;; Does the Veteran have depression, cognitive impairment or dementia, or
;; any other mental disorder attributable to ALS and/or its treatment?
;; ___ Yes ___ No
;;^TOF^
;; If yes, does the Veteran's mental disorder, as identified in the
;; question above, result in gross impairment in thought processes or
;; communication?
;; ___ Yes ___ No
;; Also complete a Mental Disorder Questionnaire (schedule with
;; appropriate provider).
;; If yes, briefly describe the Veteran's mental disorder: ________________
;;
;; ________________________________________________________________________
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQAL2 14638 printed Nov 22, 2024@16:55:43 Page 2
DVBCQAL2 ;;ALB-CIOFO/ECF - AMYOTROPHIC LATERAL SCLEROSIS (ALS) QUESTIONNAIRE ; 5/15/2011
+1 ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran now have or has he/she ever been diagnosed with Amyotrophic
+10 ;; Lateral Sclerosis (ALS)?
+11 ;; ___ Yes ___ No
+12 ;;
+13 ;; If yes, provide only diagnoses that pertain to ALS:
+14 ;;
+15 ;; Diagnosis #1: ______________________________
+16 ;; ICD code: __________________________________
+17 ;; Date of diagnosis: _________________________
+18 ;;
+19 ;; Diagnosis #2: ______________________________
+20 ;; ICD code: __________________________________
+21 ;; Date of diagnosis: _________________________
+22 ;;
+23 ;; Diagnosis #3: ______________________________
+24 ;; ICD code: __________________________________
+25 ;; Date of diagnosis: _________________________
+26 ;;
+27 ;; If there are additional diagnoses that pertain to ALS, list using above
+28 ;; format: ____________________________________________________________________
+29 ;;
+30 ;; 2. Medical history
+31 ;;
+32 ;; a. Describe the history (including onset and course) of the Veteran's ALS
+33 ;; (brief summary):
+34 ;;
+35 ;; ____________________________________________________________________________
+36 ;;
+37 ;; b. Dominant hand
+38 ;;
+39 ;; ___ Right ___ Left ___ Ambidextrous
+40 ;;
+41 ;; 3. Conditions, signs and symptoms due to ALS
+42 ;;
+43 ;; a. Does the Veteran have any muscle weakness in the upper and/or lower
+44 ;; extremities attributable to ALS?
+45 ;; ___ Yes ___ No
+46 ;; If yes, report under strength testing in neurologic exam section.
+47 ;;^TOF^
+48 ;; b. Does the Veteran have any pharynx and/or larynx and/or swallowing
+49 ;; conditions attributable to ALS?
+50 ;; ___ Yes ___ No
+51 ;;
+52 ;; If yes, check all that apply:
+53 ;; ____ Constant inability to communicate by speech
+54 ;; ____ Speech not intelligible or individual is aphonic
+55 ;; ____ Paralysis of soft palate with swallowing difficulty (nasal
+56 ;; regurgitation) and speech impairment
+57 ;; ____ Hoarseness
+58 ;; ____ Mild swallowing difficulties
+59 ;; ____ Moderate swallowing difficulties
+60 ;; ____ Severe swallowing difficulties, permitting passage of liquids only
+61 ;; ____ Requires feeding tube due to swallowing difficulties
+62 ;; ____ Other, describe: ____________________________________________________
+63 ;;
+64 ;; c. Does the Veteran have any respiratory conditions attributable to ALS?
+65 ;; ___ Yes ___ No
+66 ;;
+67 ;; If yes, provide PFT results under 'Diagnostic testing' section.
+68 ;;
+69 ;; d. Does the Veteran have signs and/or symptoms of sleep apnea or sleep
+70 ;; apnea-like condition attributable to ALS?
+71 ;;
+72 ;; NOTE: If signs and/or symptoms of sleep apnea or sleep apnea-like condition
+73 ;; are due ALS, these symptoms are due to weakness in the palatal, pharyngeal,
+74 ;; laryngeal, and/or respiratory musculature. A sleep study is not indicated to
+75 ;; report symptoms of sleep apnea or sleep apnea-like conditions that are
+76 ;; attributable to ALS.
+77 ;; ___ Yes ___ No
+78 ;;
+79 ;; If yes, check all that apply:
+80 ;; ___ Persistent daytime hypersomnolence
+81 ;; ___ Requires use of breathing assistance device such as continuous
+82 ;; airway pressure (CPAP) machine
+83 ;; ___ Chronic respiratory failure with carbon dioxide retention or cor
+84 ;; pulmonale
+85 ;; ___ Requires tracheostomy
+86 ;;^TOF^
+87 ;; e. Does the Veteran have any bowel impairment attributable to ALS?
+88 ;; ___ Yes ___ No
+89 ;;
+90 ;; If yes, check all that apply:
+91 ;; ____ Slight impairment of sphincter control, without leakage
+92 ;; ____ Constant slight impairment of sphincter control, or occasional
+93 ;; moderate leakage
+94 ;; ____ Occasional involuntary bowel movements, necessitating wearing of
+95 ;; a pad
+96 ;; ____ Extensive leakage and fairly frequent involuntary bowel movements
+97 ;; ____ Total loss of bowel sphincter control
+98 ;; ____ Chronic constipation
+99 ;; ____ Other bowel impairment (describe): _________________________________
+100 ;;
+101 ;; f. Does the Veteran have voiding dysfunction causing urine leakage
+102 ;; attributable to ALS?
+103 ;; ___ Yes ___ No
+104 ;;
+105 ;; If yes, please check one:
+106 ;; ____ Does not require/does not use absorbent material
+107 ;; ____ Requires absorbent material that is changed less than 2 times per day
+108 ;; ____ Requires absorbent material that is changed 2 to 4 times per day
+109 ;; ____ Requires absorbent material that is changed more than 4 times per day
+110 ;;
+111 ;; g. Does the Veteran have voiding dysfunction causing signs and/or symptoms of
+112 ;; urinary frequency attributable to ALS?
+113 ;; ___ Yes ___ No
+114 ;;
+115 ;; If yes, check all that apply:
+116 ;; ____ Daytime voiding interval between 2 and 3 hours
+117 ;; ____ Daytime voiding interval between 1 and 2 hours
+118 ;; ____ Daytime voiding interval less than 1 hour
+119 ;; ____ Nighttime awakening to void 2 times
+120 ;; ____ Nighttime awakening to void 3 to 4 times
+121 ;; ____ Nighttime awakening to void 5 or more times
+122 ;;^TOF^
+123 ;; h. Does the Veteran have voiding dysfunction causing findings, signs and/or
+124 ;; symptoms of obstructed voiding attributable to ALS?
+125 ;; ___ Yes ___ No
+126 ;;
+127 ;; If yes, check all signs and symptoms that apply:
+128 ;; ____ Hesitancy
+129 ;; If checked, is hesitancy marked?
+130 ;; ___ Yes ___ No
+131 ;; ____ Slow or weak stream
+132 ;; If checked, is stream markedly slow or weak?
+133 ;; ___ Yes ___ No
+134 ;; ____ Decreased force of stream
+135 ;; If checked, is force of stream markedly decreased?
+136 ;; ___ Yes ___ No
+137 ;; ____ Stricture disease requiring dilatation 1 to 2 times per year
+138 ;; ____ Stricture disease requiring periodic dilatation every 2 to 3 months
+139 ;; ____ Recurrent urinary tract infections secondary to obstruction
+140 ;; ____ Uroflowmetry peak flow rate less than 10 cc/sec
+141 ;; ____ Post void residuals greater than 150 cc
+142 ;; ____ Urinary retention requiring intermittent or continuous catheterization
+143 ;;
+144 ;; i. Does the Veteran have voiding dysfunction requiring the use of an
+145 ;; appliance attributable to ALS?
+146 ;; ___ Yes ___ No
+147 ;;
+148 ;; If yes, describe appliance: ________________________________________________
+149 ;;
+150 ;; j. Does the Veteran have a history of recurrent symptomatic urinary tract
+151 ;; infections attributable to ALS?
+152 ;; ___ Yes ___ No
+153 ;;
+154 ;; If yes, check all treatments that apply:
+155 ;; ____ No treatment
+156 ;; ____ Long-term drug therapy
+157 ;; If checked, list medications used for urinary tract infection and
+158 ;; indicate dates for courses of treatment over the past 12 months:
+159 ;; _______________________________________________________________________
+160 ;; ____ Hospitalization
+161 ;; If checked, indicate frequency of hospitalization:
+162 ;; ____ 1 or 2 per year
+163 ;; ____ More than 2 per year
+164 ;; ____ Drainage
+165 ;; If checked, indicate dates when drainage performed over past 12
+166 ;; months: _______________________________________________________________
+167 ;; ____ Other management/treatment not listed above
+168 ;; Description of management/treatment including dates of treatment:
+169 ;; _______________________________________________________________________
+170 ;;^TOF^
+171 ;; k. Does the Veteran (if male) have erectile dysfunction?
+172 ;; ___ Yes ___ No
+173 ;; If yes, is the erectile dysfunction as likely as not (at least a 50%
+174 ;; probability) attributable to ALS?
+175 ;; ___ Yes ___ No
+176 ;; If no, provide the etiology of the erectile dysfunction: _____________
+177 ;;
+178 ;; ______________________________________________________________________
+179 ;;
+180 ;; If yes, is the Veteran able to achieve an erection (without medication)
+181 ;; sufficient for penetration and ejaculation?
+182 ;; ___ Yes ___ No
+183 ;; If no, is the Veteran able to achieve an erection (with medication)
+184 ;; sufficient for penetration and ejaculation?
+185 ;; ___ Yes ___ No
+186 ;;
+187 ;; 4. Neurologic exam
+188 ;;
+189 ;; a. Speech
+190 ;; ___ Normal ___ Abnormal
+191 ;; If speech is abnormal, describe: ___________________________________________
+192 ;;
+193 ;; b. Gait
+194 ;; ___ Normal ___ Abnormal, describe: _________________________________________
+195 ;; If gait is abnormal, and the Veteran has more than one medical condition
+196 ;; contributing to the abnormal gait, identify the conditions and describe each
+197 ;; condition's contribution to the abnormal gait: _____________________________
+198 ;;
+199 ;; c. Strength
+200 ;; Rate strength according to the following scale:
+201 ;; 0/5 No muscle movement
+202 ;; 1/5 Visible muscle movement, but no joint movement
+203 ;; 2/5 No movement against gravity
+204 ;; 3/5 No movement against resistance
+205 ;; 4/5 Less than normal strength
+206 ;; 5/5 Normal strength
+207 ;;
+208 ;; ___ All normal
+209 ;;
+210 ;; Elbow flexion: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+211 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+212 ;; Elbow extension: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+213 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+214 ;; Wrist flexion: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+215 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+216 ;; Wrist extension: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+217 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+218 ;;^TOF^
+219 ;; Grip: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+220 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+221 ;; Pinch (thumb to index finger):
+222 ;; Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+223 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+224 ;; Knee extension: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+225 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+226 ;; Ankle plantar flexion:
+227 ;; Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+228 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+229 ;; Ankle dorsiflexion:
+230 ;; Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+231 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+232 ;;
+233 ;; d. Deep tendon reflexes (DTRs)
+234 ;; Rate reflexes according to the following scale:
+235 ;; 0 Absent
+236 ;; 1+ Decreased
+237 ;; 2+ Normal
+238 ;; 3+ Increased without clonus
+239 ;; 4+ Increased with clonus
+240 ;;
+241 ;; ___ All normal
+242 ;;
+243 ;; Biceps: Right: __0 __1+ __2+ __3+ __4+
+244 ;; Left: __0 __1+ __2+ __3+ __4+
+245 ;; Triceps: Right: __0 __1+ __2+ __3+ __4+
+246 ;; Left: __0 __1+ __2+ __3+ __4+
+247 ;; Brachioradialis: Right: __0 __1+ __2+ __3+ __4+
+248 ;; Left: __0 __1+ __2+ __3+ __4+
+249 ;; Knee: Right: __0 __1+ __2+ __3+ __4+
+250 ;; Left: __0 __1+ __2+ __3+ __4+
+251 ;; Ankle: Right: __0 __1+ __2+ __3+ __4+
+252 ;; Left: __0 __1+ __2+ __3+ __4+
+253 ;;
+254 ;; e. Plantar (Babinski) reflex
+255 ;;
+256 ;; Right: ___ plantar flexion (normal, or negative Babinski)
+257 ;; ___ dorsiflexion (abnormal, or positive Babinski)
+258 ;; Left: ___ plantar flexion (normal, or negative Babinski)
+259 ;; ___ dorsiflexion (abnormal, or positive Babinski)
+260 ;;
+261 ;; f. Does the Veteran have muscle atrophy attributable to ALS?
+262 ;; ___ Yes ___ No
+263 ;;
+264 ;; If muscle atrophy is present, indicate location: ___________________________
+265 ;; When possible, provide difference measured in cm between normal and
+266 ;; atrophied side, measured at maximum muscle bulk: _____ cm.
+267 ;;^TOF^
+268 ;; g. Summary of muscle weakness in the upper and/or lower extremities
+269 ;; attributable to ALS (check all that apply):
+270 ;;
+271 ;; Right upper extremity muscle weakness:
+272 ;; ___ None __ Mild __ Moderate __ Severe
+273 ;; ___ With atrophy __ Complete (no remaining function)
+274 ;;
+275 ;; Left upper extremity muscle weakness:
+276 ;; ___ None __ Mild __ Moderate __ Severe
+277 ;; ___ With atrophy __ Complete (no remaining function)
+278 ;;
+279 ;; Right lower extremity muscle weakness:
+280 ;; ___ None __ Mild __ Moderate __ Severe
+281 ;; ___ With atrophy __ Complete (no remaining function)
+282 ;;
+283 ;; Left lower extremity muscle weakness:
+284 ;; ___ None __ Mild __ Moderate __ Severe
+285 ;; ___ With atrophy __ Complete (no remaining function)
+286 ;;
+287 ;; NOTE: If the Veteran has more than one medical condition contributing to the
+288 ;; muscle weakness, identify the condition(s) and describe each condition's
+289 ;; contribution to the muscle weakness: _______________________________________
+290 ;;
+291 ;; 5. Other pertinent physical findings, complications, conditions, signs
+292 ;; and/or symptoms
+293 ;;
+294 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+295 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+296 ;; section above?
+297 ;; ___ Yes ___ No
+298 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+299 ;; of all related scars greater than 39 square cm (6 square inches)?
+300 ;; ___ Yes ___ No
+301 ;; If yes, also complete a Scars Questionnaire.
+302 ;;
+303 ;; b. Does the Veteran have any other pertinent physical findings,
+304 ;; complications, conditions, signs or symptoms related to ALS?
+305 ;; ___ Yes ___ No
+306 ;;
+307 ;; If yes, describe (brief summary): __________________________________________
+308 ;;
+309 ;; 6. Mental health manifestations due to ALS or its treatment
+310 ;;
+311 ;; Does the Veteran have depression, cognitive impairment or dementia, or
+312 ;; any other mental disorder attributable to ALS and/or its treatment?
+313 ;; ___ Yes ___ No
+314 ;;^TOF^
+315 ;; If yes, does the Veteran's mental disorder, as identified in the
+316 ;; question above, result in gross impairment in thought processes or
+317 ;; communication?
+318 ;; ___ Yes ___ No
+319 ;; Also complete a Mental Disorder Questionnaire (schedule with
+320 ;; appropriate provider).
+321 ;; If yes, briefly describe the Veteran's mental disorder: ________________
+322 ;;
+323 ;; ________________________________________________________________________
+324 QUIT
