Routine: DVBCQAL2

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: ________________

;;

 ;;     ________________________________________________________________________

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQAL2   14638     printed  Mar 13, 2025@20:50:14                                                                                                                                                                                                   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

DVBCQAL2.m