DVBCQAN2 ;;ALB-CIOFO/ECF - ANKLE QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
;
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 had an ankle condition?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to ankle condition(s):
;; Diagnosis #1: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; Diagnosis #2: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; Diagnosis #3: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; If there are additional diagnoses pertaining to ankle conditions, list
;; using above format: ________________________________________________________
;;
;; 2. Medical history
;;
;; Describe the history (including onset and course) of the Veteran's ankle
;; condition (brief summary): _________________________________________________
;;
;; 3. Flare-ups
;;
;; Does the Veteran report that flare-ups impact the function of the ankle?
;; ___ Yes ___ No
;; If yes, document the Veteran's description of the impact of flare-ups in
;; his or her own words: ______________________________________________________
;;
;; 4. Initial range of motion (ROM) measurements:
;;
;; Measure ROM with a goniometer, rounding each measurement to the nearest 5
;; degrees. During the measurements, document the point at which painful
;; motion begins, evidenced by visible behavior such as facial expression,
;; wincing, etc. Report initial measurements below.
;;^TOF^
;; Following the initial assessment of ROM, perform repetitive use testing.
;; For VA purposes, repetitive use testing must be included in all joint
;; exams. The VA has determined that 3 repetitions of ROM (at a minimum) can
;; serve as a representative test of the effect of repetitive use. After the
;; initial measurement, reassess ROM after 3 repetitions. Report post-test
;; measurements in section 5.
;;
;; a. Right ankle plantar flexion
;; Select where plantar flexion ends (normal endpoint is 45 degrees):
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30
;; ___35 ___40 ___45 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30
;; ___35 ___40 ___45 or greater
;;
;; b. Right ankle dorsiflexion (extension)
;; Select where dorsiflexion (extension) ends (normal endpoint is
;; 20 degrees):
;; ___0 ___5 ___10 ___15 ___20 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___0 ___5 ___10 ___15 ___20 or greater
;;
;; c. Left ankle plantar flexion
;; Select where plantar flexion ends (normal endpoint is 45 degrees):
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30
;; ___35 ___40 ___45 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30
;; ___35 ___40 ___45 or greater
;;
;; d. Left ankle plantar dorsiflexion (extension)
;; Select where dorsiflexion (extension) ends (normal endpoint is
;; 20 degrees):
;; ___0 ___5 ___10 ___15 ___20 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___0 ___5 ___10 ___15 ___20 or greater
;;
;; e. If ROM does not conform to the normal range of motion identified above
;; but is normal for this Veteran (for reasons other than an ankle condition,
;; such as age, body habitus, neurologic disease), explain: ___________________
;; ____________________________________________________________________________
;;^TOF^
;; 5. ROM measurements after repetitive use testing
;;
;; a. Is the Veteran able to perform repetitive-use testing with 3
;; repetitions?
;; ___ Yes ___ No If unable, provide reason: _____________________________
;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
;; If Veteran is able to perform repetitive-use testing, measure and report
;; ROM after a minimum of 3 repetitions.
;;
;; b. Right ankle post-test ROM
;; Select where post-test plantar flexion ends:
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30
;; ___35 ___40 ___45 or greater
;;
;; Select where post-test dorsiflexion (extension) ends:
;; ___0 ___5 ___10 ___15 ___20 or greater
;;
;; c. Left ankle post-test ROM
;; Select where post-test plantar flexion ends:
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30
;; ___35 ___40 ___45 or greater
;;
;; Select where post-test dorsiflexion (extension) ends:
;; ___0 ___5 ___10 ___15 ___20 or greater
;;
;; 6. Functional loss and additional limitation in ROM
;;
;; The following section addresses reasons for functional loss, if present,
;; and additional loss of ROM after repetitive-use testing, if present. The
;; VA defines functional loss as the inability to perform normal working
;; movements of the body with normal excursion, strength, speed, coordination
;; and/or endurance.
;;
;; a. Does the Veteran have additional limitation in ROM of the ankle
;; following repetitive-use testing?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have any functional loss and/or functional impairment
;; of the ankle?
;; ___ Yes ___ No
;;^TOF^
;; c. If the Veteran has functional loss, functional impairment and/or
;; additional limitation of ROM of the ankle after repetitive use, indicate
;; the contributing factors of disability below (check all that apply and
;; indicate side affected):
;; ___ No functional loss for right lower extremity attributable to
;; claimed condition
;; ___ No functional loss for left lower extremity attributable to
;; claimed condition
;; ___ Less movement than normal ___ Right ___ Left ___ Both
;; ___ More movement than normal ___ Right ___ Left ___ Both
;; ___ Weakened movement ___ Right ___ Left ___ Both
;; ___ Excess fatigability ___ Right ___ Left ___ Both
;; ___ Incoordination, impaired ___ Right ___ Left ___ Both
;; ability to execute skilled
;; movements smoothly
;; ___ Pain on movement ___ Right ___ Left ___ Both
;; ___ Swelling ___ Right ___ Left ___ Both
;; ___ Deformity ___ Right ___ Left ___ Both
;; ___ Atrophy of disuse ___ Right ___ Left ___ Both
;; ___ Instability of station ___ Right ___ Left ___ Both
;; ___ Disturbance of locomotion ___ Right ___ Left ___ Both
;; ___ Interference with sitting, ___ Right ___ Left ___ Both
;; standing and weight-bearing
;; ___ Other, describe : ___________________________________________________
;;
;; 7. Pain (pain on palpation)
;;
;; Does the Veteran have localized tenderness or pain on palpation of
;; joints/soft tissue of either ankle?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;;
;; 8. Muscle strength testing
;;
;; Rate strength according to the following scale:
;; 0/5 No muscle movement
;; 1/5 Palpable or visible muscle contraction, but no joint movement
;; 2/5 Active movement with gravity eliminated
;; 3/5 Active movement against gravity
;; 4/5 Active movement against some resistance
;; 5/5 Normal strength
;; 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
;;^TOF^
;; 9. Joint stability
;;
;; a. Anterior drawer test
;; Is there laxity compared with opposite side?
;; ___ Yes ___ No ___ Unable to test
;; If yes, which side demonstrates laxity? ___ Right ___ Left ___ Both
;;
;; b. Talar tilt test (inversion/eversion stress)
;; Is there laxity compared with opposite side?
;; ___ Yes ___ No ___ Unable to test
;; If yes, which side demonstrates laxity? ___ Right ___ Left ___ Both
;;
;; 10. Ankylosis
;;
;; Does the Veteran have ankylosis of the ankle, subtalar and/or tarsal joint?
;; ___ Yes ___ No
;; If yes, indicate severity of ankylosis and side affected (check all that
;; apply):
;; ___ In plantar flexion, less than 30º ___ Right ___ Left ___ Both
;; ___ In plantar flexion, between 30º and 40º ___ Right ___ Left ___ Both
;; ___ In plantar flexion, at more than 40º ___ Right ___ Left ___ Both
;; ___ In dorsiflexion, between 0º and 10º ___ Right ___ Left ___ Both
;; ___ In dorsiflexion, at more than 10º ___ Right ___ Left ___ Both
;; ___ With abduction, adduction, inversion ___ Right ___ Left ___ Both
;; or eversion deformity
;; ___ In good weight-bearing position ___ Right ___ Left ___ Both
;; ___ In poor weight-bearing position ___ Right ___ Left ___ Both
;;
;; 11. Additional conditions
;;
;; Does the Veteran now have or has he or she ever had "shin splints", stress
;; fractures, Achilles tendonitis, Achilles tendon rupture, malunion of
;; calcaneus (os calcis) or talus (astragalus), or has the Veteran had a
;; talectomy (astragalectomy)?
;; ___ Yes ___ No
;; If yes, indicate condition and complete the appropriate sections below:
;; ____________________________________________________________________________
;;
;; a. ___ "Shin splints" (medial tibial stress syndrome)
;; If checked, indicate side affected: ___ Right ___ Left ___ Both
;; Describe current symptoms: ______________________________________________
;;
;; b. ___ Stress fracture of the lower extremity
;; If checked, indicate side affected: ___ Right ___ Left ___ Both
;; Describe current symptoms: ______________________________________________
;;^TOF^
;; c. ___ Achilles tendonitis or Achilles tendon rupture
;; If checked, indicate side affected: ___ Right ___ Left ___ Both
;; Describe current symptoms: ______________________________________________
;;
;; d. ___ Malunion of calcaneous (os calcis) or talus (astragalus)
;; If checked, indicate severity and side affected:
;; ___ Moderate deformity ___ Right ___ Left ___ Both
;; ___ Marked deformity ___ Right ___ Left ___ Both
;;
;; e. ___ Talectomy
;; If checked, indicate side affected: ___ Right ___ Left ___ Both
;; Describe current symptoms: ______________________________________________
;;
;; 12. Joint replacement and other surgical procedures
;;
;; a. Has the Veteran had a total ankle joint replacement?
;; ___ Yes ___ No
;; If yes, indicate side and severity of residuals.
;; ___ Right ankle
;; Date of surgery: ___________________
;; Residuals:
;; ___ None
;; ___ Intermediate degrees of residual weakness, pain and/or
;; limitation of motion
;; ___ Chronic residuals consisting of severe painful motion
;; and/or weakness
;; ___ Other, describe: _____________________________________________
;; ___ Left ankle
;; Date of surgery: ___________________
;; Residuals:
;; ___ None
;; ___ Intermediate degrees of residual weakness, pain and/or
;; limitation of motion
;; ___ Chronic residuals consisting of severe painful motion
;; or weakness
;; ___ Other, describe: ______________________________________________
;;
;; b. Has the Veteran had arthroscopic or other ankle surgery?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; Date and type of surgery: _______________________________________________
;;
;; c. Does the Veteran have any residual signs and/or symptoms due to
;; arthroscopic or other ankle surgery?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; If yes, describe residuals: _____________________________________________
;;^TOF^
;; 13. 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): __________________________________________
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQAN2 14240 printed Sep 15, 2024@21:09:51 Page 2
DVBCQAN2 ;;ALB-CIOFO/ECF - ANKLE QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA)
+3 ;; for disability benefits. VA will consider the information you provide on
+4 ;; this questionnaire as part of their evaluation in processing the Veteran's
+5 ;; claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran now have or has he/she ever had an ankle condition?
+10 ;; ___ Yes ___ No
+11 ;;
+12 ;; If yes, provide only diagnoses that pertain to ankle condition(s):
+13 ;; Diagnosis #1: ___________________
+14 ;; ICD code: ______________________
+15 ;; Date of diagnosis: ______________
+16 ;; Side affected: ___ Right ___ Left ___ Both
+17 ;;
+18 ;; Diagnosis #2: ___________________
+19 ;; ICD code: ______________________
+20 ;; Date of diagnosis: ______________
+21 ;; Side affected: ___ Right ___ Left ___ Both
+22 ;;
+23 ;; Diagnosis #3: ___________________
+24 ;; ICD code: ______________________
+25 ;; Date of diagnosis: ______________
+26 ;; Side affected: ___ Right ___ Left ___ Both
+27 ;;
+28 ;; If there are additional diagnoses pertaining to ankle conditions, list
+29 ;; using above format: ________________________________________________________
+30 ;;
+31 ;; 2. Medical history
+32 ;;
+33 ;; Describe the history (including onset and course) of the Veteran's ankle
+34 ;; condition (brief summary): _________________________________________________
+35 ;;
+36 ;; 3. Flare-ups
+37 ;;
+38 ;; Does the Veteran report that flare-ups impact the function of the ankle?
+39 ;; ___ Yes ___ No
+40 ;; If yes, document the Veteran's description of the impact of flare-ups in
+41 ;; his or her own words: ______________________________________________________
+42 ;;
+43 ;; 4. Initial range of motion (ROM) measurements:
+44 ;;
+45 ;; Measure ROM with a goniometer, rounding each measurement to the nearest 5
+46 ;; degrees. During the measurements, document the point at which painful
+47 ;; motion begins, evidenced by visible behavior such as facial expression,
+48 ;; wincing, etc. Report initial measurements below.
+49 ;;^TOF^
+50 ;; Following the initial assessment of ROM, perform repetitive use testing.
+51 ;; For VA purposes, repetitive use testing must be included in all joint
+52 ;; exams. The VA has determined that 3 repetitions of ROM (at a minimum) can
+53 ;; serve as a representative test of the effect of repetitive use. After the
+54 ;; initial measurement, reassess ROM after 3 repetitions. Report post-test
+55 ;; measurements in section 5.
+56 ;;
+57 ;; a. Right ankle plantar flexion
+58 ;; Select where plantar flexion ends (normal endpoint is 45 degrees):
+59 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30
+60 ;; ___35 ___40 ___45 or greater
+61 ;;
+62 ;; Select where objective evidence of painful motion begins:
+63 ;; ___ No objective evidence of painful motion
+64 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30
+65 ;; ___35 ___40 ___45 or greater
+66 ;;
+67 ;; b. Right ankle dorsiflexion (extension)
+68 ;; Select where dorsiflexion (extension) ends (normal endpoint is
+69 ;; 20 degrees):
+70 ;; ___0 ___5 ___10 ___15 ___20 or greater
+71 ;;
+72 ;; Select where objective evidence of painful motion begins:
+73 ;; ___ No objective evidence of painful motion
+74 ;; ___0 ___5 ___10 ___15 ___20 or greater
+75 ;;
+76 ;; c. Left ankle plantar flexion
+77 ;; Select where plantar flexion ends (normal endpoint is 45 degrees):
+78 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30
+79 ;; ___35 ___40 ___45 or greater
+80 ;;
+81 ;; Select where objective evidence of painful motion begins:
+82 ;; ___ No objective evidence of painful motion
+83 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30
+84 ;; ___35 ___40 ___45 or greater
+85 ;;
+86 ;; d. Left ankle plantar dorsiflexion (extension)
+87 ;; Select where dorsiflexion (extension) ends (normal endpoint is
+88 ;; 20 degrees):
+89 ;; ___0 ___5 ___10 ___15 ___20 or greater
+90 ;;
+91 ;; Select where objective evidence of painful motion begins:
+92 ;; ___ No objective evidence of painful motion
+93 ;; ___0 ___5 ___10 ___15 ___20 or greater
+94 ;;
+95 ;; e. If ROM does not conform to the normal range of motion identified above
+96 ;; but is normal for this Veteran (for reasons other than an ankle condition,
+97 ;; such as age, body habitus, neurologic disease), explain: ___________________
+98 ;; ____________________________________________________________________________
+99 ;;^TOF^
+100 ;; 5. ROM measurements after repetitive use testing
+101 ;;
+102 ;; a. Is the Veteran able to perform repetitive-use testing with 3
+103 ;; repetitions?
+104 ;; ___ Yes ___ No If unable, provide reason: _____________________________
+105 ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
+106 ;; If Veteran is able to perform repetitive-use testing, measure and report
+107 ;; ROM after a minimum of 3 repetitions.
+108 ;;
+109 ;; b. Right ankle post-test ROM
+110 ;; Select where post-test plantar flexion ends:
+111 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30
+112 ;; ___35 ___40 ___45 or greater
+113 ;;
+114 ;; Select where post-test dorsiflexion (extension) ends:
+115 ;; ___0 ___5 ___10 ___15 ___20 or greater
+116 ;;
+117 ;; c. Left ankle post-test ROM
+118 ;; Select where post-test plantar flexion ends:
+119 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30
+120 ;; ___35 ___40 ___45 or greater
+121 ;;
+122 ;; Select where post-test dorsiflexion (extension) ends:
+123 ;; ___0 ___5 ___10 ___15 ___20 or greater
+124 ;;
+125 ;; 6. Functional loss and additional limitation in ROM
+126 ;;
+127 ;; The following section addresses reasons for functional loss, if present,
+128 ;; and additional loss of ROM after repetitive-use testing, if present. The
+129 ;; VA defines functional loss as the inability to perform normal working
+130 ;; movements of the body with normal excursion, strength, speed, coordination
+131 ;; and/or endurance.
+132 ;;
+133 ;; a. Does the Veteran have additional limitation in ROM of the ankle
+134 ;; following repetitive-use testing?
+135 ;; ___ Yes ___ No
+136 ;;
+137 ;; b. Does the Veteran have any functional loss and/or functional impairment
+138 ;; of the ankle?
+139 ;; ___ Yes ___ No
+140 ;;^TOF^
+141 ;; c. If the Veteran has functional loss, functional impairment and/or
+142 ;; additional limitation of ROM of the ankle after repetitive use, indicate
+143 ;; the contributing factors of disability below (check all that apply and
+144 ;; indicate side affected):
+145 ;; ___ No functional loss for right lower extremity attributable to
+146 ;; claimed condition
+147 ;; ___ No functional loss for left lower extremity attributable to
+148 ;; claimed condition
+149 ;; ___ Less movement than normal ___ Right ___ Left ___ Both
+150 ;; ___ More movement than normal ___ Right ___ Left ___ Both
+151 ;; ___ Weakened movement ___ Right ___ Left ___ Both
+152 ;; ___ Excess fatigability ___ Right ___ Left ___ Both
+153 ;; ___ Incoordination, impaired ___ Right ___ Left ___ Both
+154 ;; ability to execute skilled
+155 ;; movements smoothly
+156 ;; ___ Pain on movement ___ Right ___ Left ___ Both
+157 ;; ___ Swelling ___ Right ___ Left ___ Both
+158 ;; ___ Deformity ___ Right ___ Left ___ Both
+159 ;; ___ Atrophy of disuse ___ Right ___ Left ___ Both
+160 ;; ___ Instability of station ___ Right ___ Left ___ Both
+161 ;; ___ Disturbance of locomotion ___ Right ___ Left ___ Both
+162 ;; ___ Interference with sitting, ___ Right ___ Left ___ Both
+163 ;; standing and weight-bearing
+164 ;; ___ Other, describe : ___________________________________________________
+165 ;;
+166 ;; 7. Pain (pain on palpation)
+167 ;;
+168 ;; Does the Veteran have localized tenderness or pain on palpation of
+169 ;; joints/soft tissue of either ankle?
+170 ;; ___ Yes ___ No
+171 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+172 ;;
+173 ;; 8. Muscle strength testing
+174 ;;
+175 ;; Rate strength according to the following scale:
+176 ;; 0/5 No muscle movement
+177 ;; 1/5 Palpable or visible muscle contraction, but no joint movement
+178 ;; 2/5 Active movement with gravity eliminated
+179 ;; 3/5 Active movement against gravity
+180 ;; 4/5 Active movement against some resistance
+181 ;; 5/5 Normal strength
+182 ;; Ankle plantar flexion:
+183 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+184 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+185 ;;
+186 ;; Ankle dorsiflexion:
+187 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+188 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+189 ;;^TOF^
+190 ;; 9. Joint stability
+191 ;;
+192 ;; a. Anterior drawer test
+193 ;; Is there laxity compared with opposite side?
+194 ;; ___ Yes ___ No ___ Unable to test
+195 ;; If yes, which side demonstrates laxity? ___ Right ___ Left ___ Both
+196 ;;
+197 ;; b. Talar tilt test (inversion/eversion stress)
+198 ;; Is there laxity compared with opposite side?
+199 ;; ___ Yes ___ No ___ Unable to test
+200 ;; If yes, which side demonstrates laxity? ___ Right ___ Left ___ Both
+201 ;;
+202 ;; 10. Ankylosis
+203 ;;
+204 ;; Does the Veteran have ankylosis of the ankle, subtalar and/or tarsal joint?
+205 ;; ___ Yes ___ No
+206 ;; If yes, indicate severity of ankylosis and side affected (check all that
+207 ;; apply):
+208 ;; ___ In plantar flexion, less than 30 ___ Right ___ Left ___ Both
+209 ;; ___ In plantar flexion, between 30 and 40 ___ Right ___ Left ___ Both
+210 ;; ___ In plantar flexion, at more than 40 ___ Right ___ Left ___ Both
+211 ;; ___ In dorsiflexion, between 0 and 10 ___ Right ___ Left ___ Both
+212 ;; ___ In dorsiflexion, at more than 10 ___ Right ___ Left ___ Both
+213 ;; ___ With abduction, adduction, inversion ___ Right ___ Left ___ Both
+214 ;; or eversion deformity
+215 ;; ___ In good weight-bearing position ___ Right ___ Left ___ Both
+216 ;; ___ In poor weight-bearing position ___ Right ___ Left ___ Both
+217 ;;
+218 ;; 11. Additional conditions
+219 ;;
+220 ;; Does the Veteran now have or has he or she ever had "shin splints", stress
+221 ;; fractures, Achilles tendonitis, Achilles tendon rupture, malunion of
+222 ;; calcaneus (os calcis) or talus (astragalus), or has the Veteran had a
+223 ;; talectomy (astragalectomy)?
+224 ;; ___ Yes ___ No
+225 ;; If yes, indicate condition and complete the appropriate sections below:
+226 ;; ____________________________________________________________________________
+227 ;;
+228 ;; a. ___ "Shin splints" (medial tibial stress syndrome)
+229 ;; If checked, indicate side affected: ___ Right ___ Left ___ Both
+230 ;; Describe current symptoms: ______________________________________________
+231 ;;
+232 ;; b. ___ Stress fracture of the lower extremity
+233 ;; If checked, indicate side affected: ___ Right ___ Left ___ Both
+234 ;; Describe current symptoms: ______________________________________________
+235 ;;^TOF^
+236 ;; c. ___ Achilles tendonitis or Achilles tendon rupture
+237 ;; If checked, indicate side affected: ___ Right ___ Left ___ Both
+238 ;; Describe current symptoms: ______________________________________________
+239 ;;
+240 ;; d. ___ Malunion of calcaneous (os calcis) or talus (astragalus)
+241 ;; If checked, indicate severity and side affected:
+242 ;; ___ Moderate deformity ___ Right ___ Left ___ Both
+243 ;; ___ Marked deformity ___ Right ___ Left ___ Both
+244 ;;
+245 ;; e. ___ Talectomy
+246 ;; If checked, indicate side affected: ___ Right ___ Left ___ Both
+247 ;; Describe current symptoms: ______________________________________________
+248 ;;
+249 ;; 12. Joint replacement and other surgical procedures
+250 ;;
+251 ;; a. Has the Veteran had a total ankle joint replacement?
+252 ;; ___ Yes ___ No
+253 ;; If yes, indicate side and severity of residuals.
+254 ;; ___ Right ankle
+255 ;; Date of surgery: ___________________
+256 ;; Residuals:
+257 ;; ___ None
+258 ;; ___ Intermediate degrees of residual weakness, pain and/or
+259 ;; limitation of motion
+260 ;; ___ Chronic residuals consisting of severe painful motion
+261 ;; and/or weakness
+262 ;; ___ Other, describe: _____________________________________________
+263 ;; ___ Left ankle
+264 ;; Date of surgery: ___________________
+265 ;; Residuals:
+266 ;; ___ None
+267 ;; ___ Intermediate degrees of residual weakness, pain and/or
+268 ;; limitation of motion
+269 ;; ___ Chronic residuals consisting of severe painful motion
+270 ;; or weakness
+271 ;; ___ Other, describe: ______________________________________________
+272 ;;
+273 ;; b. Has the Veteran had arthroscopic or other ankle surgery?
+274 ;; ___ Yes ___ No
+275 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+276 ;; Date and type of surgery: _______________________________________________
+277 ;;
+278 ;; c. Does the Veteran have any residual signs and/or symptoms due to
+279 ;; arthroscopic or other ankle surgery?
+280 ;; ___ Yes ___ No
+281 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+282 ;; If yes, describe residuals: _____________________________________________
+283 ;;^TOF^
+284 ;; 13. Other pertinent physical findings, complications, conditions, signs
+285 ;; and/or symptoms
+286 ;;
+287 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+288 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+289 ;; section above?
+290 ;; ___ Yes ___ No
+291 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+292 ;; of all related scars greater than 39 square cm (6 square inches)?
+293 ;; ___ Yes ___ No
+294 ;; If yes, also complete a Scars Questionnaire.
+295 ;;
+296 ;; b. Does the Veteran have any other pertinent physical findings,
+297 ;; complications, conditions, signs and/or symptoms related to any conditions
+298 ;; listed in the Diagnosis section above?
+299 ;; ___ Yes ___ No
+300 ;; If yes, describe (brief summary): __________________________________________
+301 ;;
+302 QUIT
