DVBCQAM2 ;;ALB-CIOFO/ECF,SBW - AMPUTATIONS QUESTIONNAIRE ; 21-JUN-2011
;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
;
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.
;;
;; NOTE: If there is limited motion or instability in the joint above the
;; amputation site, also complete a Questionnaire for the specific joint. If there
;; are associated muscle injuries, also complete the Muscle Injury Questionnaire.
;;
;; 1. Diagnosis
;; Has the Veteran had any amputations?
;; ___ Yes ___ No
;; If yes, provide only diagnoses that pertain to amputations:
;; Amputation #1: __________________
;; ICD code: ______________________
;; Date of amputation: _____________
;;
;; Amputation #2: __________________
;; ICD code: ______________________
;; Date of amputation: _____________
;;
;; Amputation #3: __________________
;; ICD code: ______________________
;; Date of amputation: _____________
;;
;; If additional amputations exist, list using above format: __________________
;;
;; 2. Medical history
;; a. Describe the history (including etiology and course) of each amputation
;; listed above: ______________________________________________________________
;;
;; b. Dominant hand:
;; ___ Right ___ Left ___ Ambidextrous
;;
;; 3. Amputation sites
;; Indicate affected sites:
;; ___ Upper extremities (not including fingers)
;; ___ Fingers
;; ___ Lower extremities (not including toes)
;; ___ Toes
;; For all checked sites, complete the corresponding sections below.
;;
;; 4. Upper extremities (not including fingers)
;; a. Does the Veteran have an amputation of either arm?
;; ___ Yes ___ No
;; If yes, indicate site and side affected (check all that apply):
;; ___ Below insertion of deltoid
;; ___ Right ___ Left ___ Both
;; ___ Above insertion of deltoid
;; ___ Right ___ Left ___ Both
;; ___ Disarticulation
;; ___ Right ___ Left ___ Both
;;
;; b. Does the amputation site allow the use of a suitable prosthetic appliance?
;; ___ Yes ___ No
;; If yes, indicate side that allows use of suitable prosthetic appliance:
;; ___ Right ___ Left ___ Both
;;
;; c. Does the Veteran have an amputation of either forearm?
;; ___ Yes ___ No
;; If yes, indicate site and side affected (check all that apply):
;; ___ Amputation below insertion of pronator teres
;; ___ Right ___ Left ___ Both
;; ___ Amputation above insertion of pronator teres
;; ___ Right ___ Left ___ Both
;;
;; 5. Fingers
;; a. Does the Veteran have an amputation of either thumb?
;; ___ Yes ___ No
;; If yes, indicate site and side affected (check all that apply):
;; ___ Amputation at the distal joint or through the distal phalanx
;; ___ Right ___ Left ___ Both
;; ___ Amputation at the metacarpophalangeal joint or through the proximal
;; phalanx
;; ___ Right ___ Left ___ Both
;; ___ Amputation with metacarpal resection
;; ___ Right ___ Left ___ Both
;;
;; b. Does the Veteran have an amputation of any fingers?
;; ___ Yes ___ No
;; If yes, indicate site and side affected (check all that apply):
;; ___ Amputation through the middle phalanx or at the distal joint
;; ___Right index finger ___Left index finger ___Both index fingers
;; ___Right long finger ___Left long finger ___Both long fingers
;; ___Right ring finger ___Left ring finger ___Both ring fingers
;; ___Right little finger ___Left little finger ___Both little fingers
;; ___ Amputation without metacarpal resection, at the proximal
;; interphalangeal joint or proximal thereto
;; ___Right index finger ___Left index finger ___Both index fingers
;; ___Right long finger ___Left long finger ___Both long fingers
;; ___Right ring finger ___Left ring finger ___Both ring fingers
;; ___Right little finger ___Left little finger ___Both little fingers
;; ___ Amputation with metacarpal resection (more than one-half the bone lost)
;; ___Right index finger ___Left index finger ___Both index fingers
;; ___Right long finger ___Left long finger ___Both long fingers
;; ___Right ring finger ___Left ring finger ___Both ring fingers
;; ___Right little finger ___Left little finger ___Both little fingers
;;^TOF^
;; 6. Lower extremities (not including the toes)
;; a. Does the Veteran have an above-knee amputation of the thigh?
;; ___ Yes ___ No
;; If yes, indicate site and side affected (check all that apply):
;; ___ Amputation to the middle or lower third of thigh
;; ___ Right ___ Left ___ Both
;; ___ Amputation to the upper third of thigh
;; ___ Right ___ Left ___ Both
;; ___ Disarticulation with loss of extrinsic pelvic girdle muscles
;; ___ Right ___ Left ___ Both
;;
;; b. Does the thigh amputation site allow the use of a suitable prosthetic
;; appliance?
;; ___ Yes ___ No
;; If yes, indicate side that allows use of suitable prosthetic appliance:
;; ___ Right ___ Left ___ Both
;;
;; c. Does the Veteran have a below-knee amputation of the lower leg,
;; including the forefoot?
;; ___ Yes ___ No
;; If yes, indicate site and side affected (check all that apply):
;; ___ Amputation of forefoot proximal to the metatarsal bones (more than
;; 1/2 of metatarsal loss)
;; ___ Right ___ Left ___ Both
;; ___ Amputation between the forefoot and knee, permitting prosthesis
;; ___ Right ___ Left ___ Both
;; ___ Amputation not improvable by prosthesis controlled by natural knee
;; action
;; ___ Right ___ Left ___ Both
;; ___ Amputation with defective stump and amputation to the thigh
;; recommended
;; ___ Right ___ Left ___ Both
;;
;; d. Does the lower leg amputation site allow the use of a suitable
;; prosthetic appliance?
;; ___ Yes ___ No
;; If yes, indicate side that allows use of suitable prosthetic appliance:
;; ___ Right ___ Left ___ Both
;;^TOF^
;; 7. Toes
;; Does the Veteran have an amputation of any toes?
;; ___ Yes ___ No
;; If yes, indicate site and side affected (check all that apply):
;; ___ Amputation of toes without removal of the metatarsal head
;; If checked, indicate site and side affected (check all that apply):
;; ___ Right great toe ___ Left great toe ___ Both great toes
;; ___ Right 2nd toe ___ Left 2nd toe ___ Both 2nd toes
;; ___ Right 3rd toe ___ Left 3rd toe ___ Both 3rd toes
;; ___ Right 4th toe ___ Left 4th toe ___ Both 4th toes
;; ___ Right little toe ___ Left little toe ___ Both little toes
;; ___ Amputation of toes with removal of the metatarsal head
;; If checked, indicate site and side affected (check all that apply):
;; ___ Right great toe ___ Left great toe ___ Both great toes
;; ___ Right 2nd toe ___ Left 2nd toe ___ Both 2nd toes
;; ___ Right 3rd toe ___ Left 3rd toe ___ Both 3rd toes
;; ___ Right 4th toe ___ Left 4th toe ___ Both 4th toes
;; ___ Right little toe ___ Left little toe ___ Both little toes
;;
;; 8. 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 and/or symptoms related to any conditions
;; listed in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): __________________________________________
;;
;; 9. Assistive devices
;; a. Does the Veteran use any assistive devices as a normal mode of
;; locomotion, although occasional locomotion by other methods may be possible?
;; ___ Yes ___ No
;;
;; If yes, identify assistive devices used (check all that apply and indicate
;; frequency):
;;
;; ___Wheelchair Frequency of use: ___Occasional ___Regular ___Constant
;; ___Brace(s) Frequency of use: ___Occasional ___Regular ___Constant
;; ___Crutch(es) Frequency of use: ___Occasional ___Regular ___Constant
;; ___Cane(s) Frequency of use: ___Occasional ___Regular ___Constant
;; ___Walker Frequency of use: ___Occasional ___Regular ___Constant
;; ___Other: _______________________________________________________________
;; Frequency of use: ___Occasional ___Regular ___Constant
;;
;; b. If the Veteran uses any assistive devices, specify the condition and
;; identify the assistive device used for each condition: ______________________
;;
;; ____________________________________________________________________________
;;
;; 10. Diagnostic Testing
;; NOTE: Imaging studies are not required to document amputations.
;;
;; Are there any significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;
;; 11. Functional impact
;; Do any of the Veteran's amputations impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's amputations, providing
;; one or more examples: ______________________________________________________
;;
;; 12. Remarks, if any: _______________________________________________________
;;
;; Physician signature: ____________________________________ Date: ____________
;;
;; Physician printed name: ____________________________________________________
;;
;; Medical license #: _________________________________________________________
;;
;; Physician address: _________________________________________________________
;;
;; Phone: _____________________________ FAX: ______________________________
;;
;; NOTE: VA may request additional medical information, including additional
;; examinations if necessary to complete VA's review of the Veteran's application.
;;^END^
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQAM2 11068 printed Apr 09, 2024@20:54:52 Page 2
DVBCQAM2 ;;ALB-CIOFO/ECF,SBW - AMPUTATIONS QUESTIONNAIRE ; 21-JUN-2011
+1 ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;;
+5 ;; NOTE: If there is limited motion or instability in the joint above the
+6 ;; amputation site, also complete a Questionnaire for the specific joint. If there
+7 ;; are associated muscle injuries, also complete the Muscle Injury Questionnaire.
+8 ;;
+9 ;; 1. Diagnosis
+10 ;; Has the Veteran had any amputations?
+11 ;; ___ Yes ___ No
+12 ;; If yes, provide only diagnoses that pertain to amputations:
+13 ;; Amputation #1: __________________
+14 ;; ICD code: ______________________
+15 ;; Date of amputation: _____________
+16 ;;
+17 ;; Amputation #2: __________________
+18 ;; ICD code: ______________________
+19 ;; Date of amputation: _____________
+20 ;;
+21 ;; Amputation #3: __________________
+22 ;; ICD code: ______________________
+23 ;; Date of amputation: _____________
+24 ;;
+25 ;; If additional amputations exist, list using above format: __________________
+26 ;;
+27 ;; 2. Medical history
+28 ;; a. Describe the history (including etiology and course) of each amputation
+29 ;; listed above: ______________________________________________________________
+30 ;;
+31 ;; b. Dominant hand:
+32 ;; ___ Right ___ Left ___ Ambidextrous
+33 ;;
+34 ;; 3. Amputation sites
+35 ;; Indicate affected sites:
+36 ;; ___ Upper extremities (not including fingers)
+37 ;; ___ Fingers
+38 ;; ___ Lower extremities (not including toes)
+39 ;; ___ Toes
+40 ;; For all checked sites, complete the corresponding sections below.
+41 ;;
+42 ;; 4. Upper extremities (not including fingers)
+43 ;; a. Does the Veteran have an amputation of either arm?
+44 ;; ___ Yes ___ No
+45 ;; If yes, indicate site and side affected (check all that apply):
+46 ;; ___ Below insertion of deltoid
+47 ;; ___ Right ___ Left ___ Both
+48 ;; ___ Above insertion of deltoid
+49 ;; ___ Right ___ Left ___ Both
+50 ;; ___ Disarticulation
+51 ;; ___ Right ___ Left ___ Both
+52 ;;
+53 ;; b. Does the amputation site allow the use of a suitable prosthetic appliance?
+54 ;; ___ Yes ___ No
+55 ;; If yes, indicate side that allows use of suitable prosthetic appliance:
+56 ;; ___ Right ___ Left ___ Both
+57 ;;
+58 ;; c. Does the Veteran have an amputation of either forearm?
+59 ;; ___ Yes ___ No
+60 ;; If yes, indicate site and side affected (check all that apply):
+61 ;; ___ Amputation below insertion of pronator teres
+62 ;; ___ Right ___ Left ___ Both
+63 ;; ___ Amputation above insertion of pronator teres
+64 ;; ___ Right ___ Left ___ Both
+65 ;;
+66 ;; 5. Fingers
+67 ;; a. Does the Veteran have an amputation of either thumb?
+68 ;; ___ Yes ___ No
+69 ;; If yes, indicate site and side affected (check all that apply):
+70 ;; ___ Amputation at the distal joint or through the distal phalanx
+71 ;; ___ Right ___ Left ___ Both
+72 ;; ___ Amputation at the metacarpophalangeal joint or through the proximal
+73 ;; phalanx
+74 ;; ___ Right ___ Left ___ Both
+75 ;; ___ Amputation with metacarpal resection
+76 ;; ___ Right ___ Left ___ Both
+77 ;;
+78 ;; b. Does the Veteran have an amputation of any fingers?
+79 ;; ___ Yes ___ No
+80 ;; If yes, indicate site and side affected (check all that apply):
+81 ;; ___ Amputation through the middle phalanx or at the distal joint
+82 ;; ___Right index finger ___Left index finger ___Both index fingers
+83 ;; ___Right long finger ___Left long finger ___Both long fingers
+84 ;; ___Right ring finger ___Left ring finger ___Both ring fingers
+85 ;; ___Right little finger ___Left little finger ___Both little fingers
+86 ;; ___ Amputation without metacarpal resection, at the proximal
+87 ;; interphalangeal joint or proximal thereto
+88 ;; ___Right index finger ___Left index finger ___Both index fingers
+89 ;; ___Right long finger ___Left long finger ___Both long fingers
+90 ;; ___Right ring finger ___Left ring finger ___Both ring fingers
+91 ;; ___Right little finger ___Left little finger ___Both little fingers
+92 ;; ___ Amputation with metacarpal resection (more than one-half the bone lost)
+93 ;; ___Right index finger ___Left index finger ___Both index fingers
+94 ;; ___Right long finger ___Left long finger ___Both long fingers
+95 ;; ___Right ring finger ___Left ring finger ___Both ring fingers
+96 ;; ___Right little finger ___Left little finger ___Both little fingers
+97 ;;^TOF^
+98 ;; 6. Lower extremities (not including the toes)
+99 ;; a. Does the Veteran have an above-knee amputation of the thigh?
+100 ;; ___ Yes ___ No
+101 ;; If yes, indicate site and side affected (check all that apply):
+102 ;; ___ Amputation to the middle or lower third of thigh
+103 ;; ___ Right ___ Left ___ Both
+104 ;; ___ Amputation to the upper third of thigh
+105 ;; ___ Right ___ Left ___ Both
+106 ;; ___ Disarticulation with loss of extrinsic pelvic girdle muscles
+107 ;; ___ Right ___ Left ___ Both
+108 ;;
+109 ;; b. Does the thigh amputation site allow the use of a suitable prosthetic
+110 ;; appliance?
+111 ;; ___ Yes ___ No
+112 ;; If yes, indicate side that allows use of suitable prosthetic appliance:
+113 ;; ___ Right ___ Left ___ Both
+114 ;;
+115 ;; c. Does the Veteran have a below-knee amputation of the lower leg,
+116 ;; including the forefoot?
+117 ;; ___ Yes ___ No
+118 ;; If yes, indicate site and side affected (check all that apply):
+119 ;; ___ Amputation of forefoot proximal to the metatarsal bones (more than
+120 ;; 1/2 of metatarsal loss)
+121 ;; ___ Right ___ Left ___ Both
+122 ;; ___ Amputation between the forefoot and knee, permitting prosthesis
+123 ;; ___ Right ___ Left ___ Both
+124 ;; ___ Amputation not improvable by prosthesis controlled by natural knee
+125 ;; action
+126 ;; ___ Right ___ Left ___ Both
+127 ;; ___ Amputation with defective stump and amputation to the thigh
+128 ;; recommended
+129 ;; ___ Right ___ Left ___ Both
+130 ;;
+131 ;; d. Does the lower leg amputation site allow the use of a suitable
+132 ;; prosthetic appliance?
+133 ;; ___ Yes ___ No
+134 ;; If yes, indicate side that allows use of suitable prosthetic appliance:
+135 ;; ___ Right ___ Left ___ Both
+136 ;;^TOF^
+137 ;; 7. Toes
+138 ;; Does the Veteran have an amputation of any toes?
+139 ;; ___ Yes ___ No
+140 ;; If yes, indicate site and side affected (check all that apply):
+141 ;; ___ Amputation of toes without removal of the metatarsal head
+142 ;; If checked, indicate site and side affected (check all that apply):
+143 ;; ___ Right great toe ___ Left great toe ___ Both great toes
+144 ;; ___ Right 2nd toe ___ Left 2nd toe ___ Both 2nd toes
+145 ;; ___ Right 3rd toe ___ Left 3rd toe ___ Both 3rd toes
+146 ;; ___ Right 4th toe ___ Left 4th toe ___ Both 4th toes
+147 ;; ___ Right little toe ___ Left little toe ___ Both little toes
+148 ;; ___ Amputation of toes with removal of the metatarsal head
+149 ;; If checked, indicate site and side affected (check all that apply):
+150 ;; ___ Right great toe ___ Left great toe ___ Both great toes
+151 ;; ___ Right 2nd toe ___ Left 2nd toe ___ Both 2nd toes
+152 ;; ___ Right 3rd toe ___ Left 3rd toe ___ Both 3rd toes
+153 ;; ___ Right 4th toe ___ Left 4th toe ___ Both 4th toes
+154 ;; ___ Right little toe ___ Left little toe ___ Both little toes
+155 ;;
+156 ;; 8. Other pertinent physical findings, complications, conditions, signs
+157 ;; and/or symptoms
+158 ;; a. Does the Veteran have any scars (surgical or otherwise) related to
+159 ;; any conditions or to the treatment of any conditions listed in the
+160 ;; Diagnosis section above?
+161 ;; ___ Yes ___ No
+162 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+163 ;; of all related scars greater than 39 square cm (6 square inches)?
+164 ;; ___ Yes ___ No
+165 ;; If yes, also complete a Scars Questionnaire.
+166 ;;
+167 ;; b. Does the Veteran have any other pertinent physical findings,
+168 ;; complications, conditions, signs and/or symptoms related to any conditions
+169 ;; listed in the Diagnosis section above?
+170 ;; ___ Yes ___ No
+171 ;; If yes, describe (brief summary): __________________________________________
+172 ;;
+173 ;; 9. Assistive devices
+174 ;; a. Does the Veteran use any assistive devices as a normal mode of
+175 ;; locomotion, although occasional locomotion by other methods may be possible?
+176 ;; ___ Yes ___ No
+177 ;;
+178 ;; If yes, identify assistive devices used (check all that apply and indicate
+179 ;; frequency):
+180 ;;
+181 ;; ___Wheelchair Frequency of use: ___Occasional ___Regular ___Constant
+182 ;; ___Brace(s) Frequency of use: ___Occasional ___Regular ___Constant
+183 ;; ___Crutch(es) Frequency of use: ___Occasional ___Regular ___Constant
+184 ;; ___Cane(s) Frequency of use: ___Occasional ___Regular ___Constant
+185 ;; ___Walker Frequency of use: ___Occasional ___Regular ___Constant
+186 ;; ___Other: _______________________________________________________________
+187 ;; Frequency of use: ___Occasional ___Regular ___Constant
+188 ;;
+189 ;; b. If the Veteran uses any assistive devices, specify the condition and
+190 ;; identify the assistive device used for each condition: ______________________
+191 ;;
+192 ;; ____________________________________________________________________________
+193 ;;
+194 ;; 10. Diagnostic Testing
+195 ;; NOTE: Imaging studies are not required to document amputations.
+196 ;;
+197 ;; Are there any significant diagnostic test findings and/or results?
+198 ;; ___ Yes ___ No
+199 ;; If yes, provide type of test or procedure, date and results (brief summary):
+200 ;; ____________________________________________________________________________
+201 ;;
+202 ;; 11. Functional impact
+203 ;; Do any of the Veteran's amputations impact his or her ability to work?
+204 ;; ___ Yes ___ No
+205 ;; If yes, describe the impact of each of the Veteran's amputations, providing
+206 ;; one or more examples: ______________________________________________________
+207 ;;
+208 ;; 12. Remarks, if any: _______________________________________________________
+209 ;;
+210 ;; Physician signature: ____________________________________ Date: ____________
+211 ;;
+212 ;; Physician printed name: ____________________________________________________
+213 ;;
+214 ;; Medical license #: _________________________________________________________
+215 ;;
+216 ;; Physician address: _________________________________________________________
+217 ;;
+218 ;; Phone: _____________________________ FAX: ______________________________
+219 ;;
+220 ;; NOTE: VA may request additional medical information, including additional
+221 ;; examinations if necessary to complete VA's review of the Veteran's application.
+222 ;;^END^
+223 QUIT
