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Routine: DVBCQAN2

DVBCQAN2.m

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  1. DVBCQAN2 ;;ALB-CIOFO/ECF -  ANKLE QUESTIONNAIRE ; 6/15/2011
  1.  ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA)
  1.  ;; for disability benefits.  VA will consider the information you provide on
  1.  ;; this questionnaire as part of their evaluation in processing the Veteran's
  1.  ;; claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;;
  1.  ;; Does the Veteran now have or has he/she ever had an ankle condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide only diagnoses that pertain to ankle condition(s):
  1.  ;; Diagnosis #1: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;; Side affected: ___ Right   ___ Left   ___ Both
  1.  ;; 
  1.  ;; Diagnosis #2: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;; Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; Diagnosis #3: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;; Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; If there are additional diagnoses pertaining to ankle conditions, list
  1.  ;; using above format: ________________________________________________________
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;;
  1.  ;; Describe the history (including onset and course) of the Veteran's ankle
  1.  ;; condition (brief summary): _________________________________________________
  1.  ;;
  1.  ;; 3. Flare-ups
  1.  ;;
  1.  ;; Does the Veteran report that flare-ups impact the function of the ankle?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, document the Veteran's description of the impact of flare-ups in
  1.  ;; his or her own words: ______________________________________________________
  1.  ;;
  1.  ;; 4. Initial range of motion (ROM) measurements:
  1.  ;;
  1.  ;; Measure ROM with a goniometer, rounding each measurement to the nearest 5
  1.  ;; degrees. During the measurements, document the point at which painful
  1.  ;; motion begins, evidenced by visible behavior such as facial expression,
  1.  ;; wincing, etc. Report initial measurements below.
  1.  ;;^TOF^
  1.  ;; Following the initial assessment of ROM, perform repetitive use testing.
  1.  ;; For VA purposes, repetitive use testing must be included in all joint
  1.  ;; exams. The VA has determined that 3 repetitions of ROM (at a minimum) can
  1.  ;; serve as a representative test of the effect of repetitive use. After the
  1.  ;; initial measurement, reassess ROM after 3 repetitions. Report post-test
  1.  ;; measurements in section 5.
  1.  ;;
  1.  ;; a. Right ankle plantar flexion
  1.  ;;    Select where plantar flexion ends (normal endpoint is 45 degrees):
  1.  ;;    ___0     ___5      ___10   ___15   ___20    ___25    ___30
  1.  ;;    ___35    ___40    ___45 or greater
  1.  ;;
  1.  ;;    Select where objective evidence of painful motion begins:
  1.  ;;    ___ No objective evidence of painful motion
  1.  ;;    ___0     ___5      ___10   ___15   ___20    ___25    ___30
  1.  ;;    ___35    ___40    ___45 or greater
  1.  ;;
  1.  ;; b. Right ankle dorsiflexion (extension)
  1.  ;;    Select where dorsiflexion (extension) ends (normal endpoint is
  1.  ;;    20 degrees):
  1.  ;;    ___0     ___5      ___10   ___15   ___20 or greater
  1.  ;;
  1.  ;;    Select where objective evidence of painful motion begins:
  1.  ;;    ___ No objective evidence of painful motion
  1.  ;;    ___0     ___5      ___10   ___15   ___20 or greater
  1.  ;;
  1.  ;; c. Left ankle plantar flexion
  1.  ;;    Select where plantar flexion ends (normal endpoint is 45 degrees):
  1.  ;;    ___0     ___5      ___10   ___15   ___20    ___25    ___30
  1.  ;;    ___35    ___40    ___45 or greater
  1.  ;;
  1.  ;;    Select where objective evidence of painful motion begins:
  1.  ;;    ___ No objective evidence of painful motion
  1.  ;;    ___0     ___5      ___10   ___15   ___20    ___25    ___30
  1.  ;;    ___35    ___40    ___45 or greater
  1.  ;;
  1.  ;; d. Left ankle plantar dorsiflexion (extension)
  1.  ;;    Select where dorsiflexion (extension) ends (normal endpoint is
  1.  ;;    20 degrees):
  1.  ;;    ___0     ___5      ___10   ___15   ___20 or greater
  1.  ;;
  1.  ;;    Select where objective evidence of painful motion begins:
  1.  ;;    ___ No objective evidence of painful motion
  1.  ;;    ___0     ___5      ___10   ___15   ___20 or greater
  1.  ;;
  1.  ;; e. If ROM does not conform to the normal range of motion identified above
  1.  ;; but is normal for this Veteran (for reasons other than an ankle condition,
  1.  ;; such as age, body habitus, neurologic disease), explain: ___________________
  1.  ;; ____________________________________________________________________________
  1.  ;;^TOF^
  1.  ;; 5. ROM measurements after repetitive use testing
  1.  ;;
  1.  ;; a. Is the Veteran able to perform repetitive-use testing with 3
  1.  ;; repetitions?
  1.  ;; ___ Yes   ___ No    If unable, provide reason: _____________________________
  1.  ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
  1.  ;; If Veteran is able to perform repetitive-use testing, measure and report
  1.  ;; ROM after a minimum of 3 repetitions.
  1.  ;;
  1.  ;; b. Right ankle post-test ROM
  1.  ;;    Select where post-test plantar flexion ends:
  1.  ;;    ___0     ___5      ___10   ___15   ___20    ___25    ___30
  1.  ;;    ___35    ___40    ___45 or greater
  1.  ;;
  1.  ;;    Select where post-test dorsiflexion (extension) ends:
  1.  ;;    ___0     ___5      ___10   ___15   ___20 or greater
  1.  ;;
  1.  ;; c. Left ankle post-test ROM
  1.  ;;    Select where post-test plantar flexion ends:
  1.  ;;    ___0     ___5      ___10   ___15   ___20    ___25    ___30
  1.  ;;    ___35    ___40    ___45 or greater
  1.  ;;
  1.  ;;    Select where post-test dorsiflexion (extension) ends:
  1.  ;;    ___0     ___5      ___10   ___15   ___20 or greater
  1.  ;;
  1.  ;; 6. Functional loss and additional limitation in ROM
  1.  ;;
  1.  ;; The following section addresses reasons for functional loss, if present,
  1.  ;; and additional loss of ROM after repetitive-use testing, if present. The
  1.  ;; VA defines functional loss as the inability to perform normal working
  1.  ;; movements of the body with normal excursion, strength, speed, coordination
  1.  ;; and/or endurance.
  1.  ;;
  1.  ;; a. Does the Veteran have additional limitation in ROM of the ankle
  1.  ;; following repetitive-use testing?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; b. Does the Veteran have any functional loss and/or functional impairment
  1.  ;; of the ankle?
  1.  ;; ___ Yes   ___ No
  1.  ;;^TOF^
  1.  ;; c. If the Veteran has functional loss, functional impairment and/or
  1.  ;; additional limitation of ROM of the ankle after repetitive use, indicate
  1.  ;; the contributing factors of disability below (check all that apply and
  1.  ;; indicate side affected):
  1.  ;;    ___ No functional loss for right lower extremity attributable to
  1.  ;;        claimed condition
  1.  ;;    ___ No functional loss for left lower extremity attributable to
  1.  ;;        claimed condition
  1.  ;;    ___ Less movement than normal      ___ Right   ___ Left   ___ Both
  1.  ;;    ___ More movement than normal      ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Weakened movement              ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Excess fatigability            ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Incoordination, impaired       ___ Right   ___ Left   ___ Both
  1.  ;;        ability to execute skilled
  1.  ;;        movements smoothly
  1.  ;;    ___ Pain on movement               ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Swelling                       ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Deformity                      ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Atrophy of disuse              ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Instability of station         ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Disturbance of locomotion      ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Interference with sitting,     ___ Right   ___ Left   ___ Both
  1.  ;;        standing and weight-bearing
  1.  ;;    ___ Other, describe : ___________________________________________________
  1.  ;;
  1.  ;; 7. Pain (pain on palpation)
  1.  ;;
  1.  ;; Does the Veteran have localized tenderness or pain on palpation of
  1.  ;; joints/soft tissue of either ankle?
  1.  ;; ___ Yes   ___ No
  1.  ;;    If yes, indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; 8. Muscle strength testing
  1.  ;;
  1.  ;; Rate strength according to the following scale:
  1.  ;;    0/5 No muscle movement
  1.  ;;    1/5 Palpable or visible muscle contraction, but no joint movement
  1.  ;;    2/5 Active movement with gravity eliminated
  1.  ;;    3/5 Active movement against gravity
  1.  ;;    4/5 Active movement against some resistance
  1.  ;;    5/5 Normal strength
  1.  ;; Ankle plantar flexion:
  1.  ;;    Right:   ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:    ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;
  1.  ;; Ankle dorsiflexion:
  1.  ;;    Right:   ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:    ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;^TOF^
  1.  ;; 9. Joint stability
  1.  ;;
  1.  ;; a. Anterior drawer test
  1.  ;; Is there laxity compared with opposite side?
  1.  ;;    ___ Yes   ___ No   ___ Unable to test
  1.  ;;    If yes, which side demonstrates laxity? ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Talar tilt test (inversion/eversion stress)
  1.  ;;    Is there laxity compared with opposite side?
  1.  ;;    ___ Yes   ___ No   ___ Unable to test
  1.  ;;    If yes, which side demonstrates laxity? ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; 10. Ankylosis
  1.  ;;
  1.  ;; Does the Veteran have ankylosis of the ankle, subtalar and/or tarsal joint?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate severity of ankylosis and side affected (check all that
  1.  ;; apply):
  1.  ;;   ___ In plantar flexion, less than 30º       ___ Right  ___ Left  ___ Both
  1.  ;;   ___ In plantar flexion, between 30º and 40º ___ Right  ___ Left  ___ Both
  1.  ;;   ___ In plantar flexion, at more than 40º    ___ Right  ___ Left  ___ Both
  1.  ;;   ___ In dorsiflexion, between 0º and 10º     ___ Right  ___ Left  ___ Both
  1.  ;;   ___ In dorsiflexion, at more than 10º       ___ Right  ___ Left  ___ Both
  1.  ;;   ___ With abduction, adduction, inversion    ___ Right  ___ Left  ___ Both
  1.  ;;       or eversion deformity
  1.  ;;   ___ In good weight-bearing position         ___ Right  ___ Left  ___ Both
  1.  ;;   ___ In poor weight-bearing position         ___ Right  ___ Left  ___ Both
  1.  ;;
  1.  ;; 11. Additional conditions
  1.  ;;
  1.  ;; Does the Veteran now have or has he or she ever had  "shin splints", stress
  1.  ;; fractures, Achilles tendonitis, Achilles tendon rupture, malunion of
  1.  ;; calcaneus (os calcis) or talus (astragalus), or has the Veteran had a
  1.  ;; talectomy (astragalectomy)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate condition and complete the appropriate sections below:
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; a. ___ "Shin splints" (medial tibial stress syndrome)
  1.  ;; If checked, indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;    Describe current symptoms: ______________________________________________
  1.  ;;
  1.  ;; b. ___ Stress fracture of the lower extremity
  1.  ;; If checked, indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;    Describe current symptoms: ______________________________________________
  1.  ;;^TOF^
  1.  ;; c. ___ Achilles tendonitis or Achilles tendon rupture
  1.  ;; If checked, indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;    Describe current symptoms: ______________________________________________
  1.  ;;
  1.  ;; d. ___ Malunion of calcaneous (os calcis) or talus (astragalus)
  1.  ;; If checked, indicate severity and side affected:
  1.  ;;    ___ Moderate deformity ___ Right  ___ Left   ___ Both
  1.  ;;    ___ Marked deformity   ___ Right  ___ Left   ___ Both
  1.  ;;
  1.  ;; e. ___  Talectomy
  1.  ;; If checked, indicate side affected:  ___ Right   ___ Left   ___ Both
  1.  ;;    Describe current symptoms: ______________________________________________
  1.  ;; 
  1.  ;; 12.  Joint replacement and other surgical procedures
  1.  ;;
  1.  ;; a. Has the Veteran had a total ankle joint replacement?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side and severity of residuals.
  1.  ;;    ___ Right ankle
  1.  ;;        Date of surgery: ___________________
  1.  ;;           Residuals:
  1.  ;;           ___ None
  1.  ;;           ___ Intermediate degrees of residual weakness, pain and/or
  1.  ;;               limitation of motion
  1.  ;;           ___ Chronic residuals consisting of severe painful motion
  1.  ;;               and/or weakness
  1.  ;;           ___ Other, describe: _____________________________________________
  1.  ;;   ___ Left ankle
  1.  ;;       Date of surgery: ___________________
  1.  ;;          Residuals:
  1.  ;;          ___ None
  1.  ;;          ___ Intermediate degrees of residual weakness, pain and/or
  1.  ;;              limitation of motion
  1.  ;;          ___ Chronic residuals consisting of severe painful motion
  1.  ;;              or weakness
  1.  ;;          ___ Other, describe: ______________________________________________
  1.  ;;
  1.  ;; b. Has the Veteran had arthroscopic or other ankle surgery?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;    Date and type of surgery: _______________________________________________
  1.  ;;
  1.  ;; c. Does the Veteran have any residual signs and/or symptoms due to
  1.  ;; arthroscopic or other ankle surgery?
  1.  ;; ___ Yes    ___ No
  1.  ;; If yes, indicate side affected:    ___ Right   ___ Left   ___ Both
  1.  ;;    If yes, describe residuals: _____________________________________________
  1.  ;;^TOF^
  1.  ;; 13. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, are any of the scars painful and/or unstable, or is the total area
  1.  ;; of all related scars greater than 39 square cm (6 square inches)?
  1.  ;;    ___ Yes   ___ No
  1.  ;;    If yes, also complete a Scars Questionnaire.
  1.  ;;
  1.  ;; b.  Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs and/or symptoms related to any conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): __________________________________________
  1.  ;;
  1.  Q