DVBCQAN3 ;;ALB-CIOFO/ECF - ANKLE QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
;
TXT ;
;;
;; 14. Assistive devices
;;
;; a. Does the Veteran use any assistive device(s) as a normal mode of
;; locomotion, although occasional locomotion by other methods may be possible?
;; ___ Yes ___ No
;;
;; If yes, identify assistive device(s) 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: ______________________
;;
;; ____________________________________________________________________________
;;^TOF^
;; 15. Remaining effective function of the extremities
;;
;; Due to the Veteran's ankle condition(s), is there functional impairment of
;; an extremity such that no effective function remains other than that which
;; would be equally well served by an amputation with prosthesis? (Functions
;; of the upper extremity include grasping, manipulation, etc., while
;; functions for the lower extremity include balance and propulsion, etc.)
;; ___ Yes, functioning is so diminished that amputation with prosthesis would
;; equally serve the Veteran.
;; ___ No
;;
;; If yes, indicate extremities for which this applies:
;; ___ Right lower ___ Left lower
;; For each checked extremity, identify the condition causing loss of
;; function, describe loss of effective function and provide specific
;; examples (brief summary): _______________________________________________
;;
;; 16. Diagnostic Testing
;;
;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
;; arthritis must be confirmed by imaging studies. Once such arthritis has
;; been documented, no further imaging studies are required by VA, even if
;; arthritis has worsened.
;;
;; a. Have imaging studies of the ankle been performed and are the results
;; available?
;; ___ Yes ___ No
;; If yes, are there abnormal findings?
;; ___ Yes ___ No
;; If yes, indicate findings:
;; ___ Degenerative or traumatic arthritis
;; ankle: ___ Right ___ Left ___ Both
;; ___ Ankylosis
;; ankle: ___ Right ___ Left ___ Both
;; ___ Other. Describe: ____________________
;; ankle: ___ Right ___ Left ___ Both
;;
;; b. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;
;; 17. Functional impact
;;
;; Does the Veteran's ankle condition impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's ankle conditions
;; providing one or more examples: ____________________________________________
;;^TOF^
;; 18. 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[HDVBCQAN3 4260 printed Dec 13, 2024@01:45:37 Page 2
DVBCQAN3 ;;ALB-CIOFO/ECF - ANKLE QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;;
+2 ;; 14. Assistive devices
+3 ;;
+4 ;; a. Does the Veteran use any assistive device(s) as a normal mode of
+5 ;; locomotion, although occasional locomotion by other methods may be possible?
+6 ;; ___ Yes ___ No
+7 ;;
+8 ;; If yes, identify assistive device(s) used (check all that apply and indicate
+9 ;; frequency):
+10 ;;
+11 ;; ___ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
+12 ;; ___ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
+13 ;; ___ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
+14 ;; ___ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
+15 ;; ___ Walker Frequency of use: __ Occasional __ Regular __ Constant
+16 ;; ___ Other: _______________________________________________________________
+17 ;; Frequency of use: __ Occasional __ Regular __ Constant
+18 ;;
+19 ;; b. If the Veteran uses any assistive devices, specify the condition and
+20 ; identify the assistive device used for each condition: ______________________
+21 ;;
+22 ;; ____________________________________________________________________________
+23 ;;^TOF^
+24 ;; 15. Remaining effective function of the extremities
+25 ;;
+26 ;; Due to the Veteran's ankle condition(s), is there functional impairment of
+27 ;; an extremity such that no effective function remains other than that which
+28 ;; would be equally well served by an amputation with prosthesis? (Functions
+29 ;; of the upper extremity include grasping, manipulation, etc., while
+30 ;; functions for the lower extremity include balance and propulsion, etc.)
+31 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+32 ;; equally serve the Veteran.
+33 ;; ___ No
+34 ;;
+35 ;; If yes, indicate extremities for which this applies:
+36 ;; ___ Right lower ___ Left lower
+37 ;; For each checked extremity, identify the condition causing loss of
+38 ;; function, describe loss of effective function and provide specific
+39 ;; examples (brief summary): _______________________________________________
+40 ;;
+41 ;; 16. Diagnostic Testing
+42 ;;
+43 ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
+44 ;; arthritis must be confirmed by imaging studies. Once such arthritis has
+45 ;; been documented, no further imaging studies are required by VA, even if
+46 ;; arthritis has worsened.
+47 ;;
+48 ;; a. Have imaging studies of the ankle been performed and are the results
+49 ;; available?
+50 ;; ___ Yes ___ No
+51 ;; If yes, are there abnormal findings?
+52 ;; ___ Yes ___ No
+53 ;; If yes, indicate findings:
+54 ;; ___ Degenerative or traumatic arthritis
+55 ;; ankle: ___ Right ___ Left ___ Both
+56 ;; ___ Ankylosis
+57 ;; ankle: ___ Right ___ Left ___ Both
+58 ;; ___ Other. Describe: ____________________
+59 ;; ankle: ___ Right ___ Left ___ Both
+60 ;;
+61 ;; b. Are there any other significant diagnostic test findings and/or results?
+62 ;; ___ Yes ___ No
+63 ;; If yes, provide type of test or procedure, date and results (brief summary):
+64 ;; ____________________________________________________________________________
+65 ;;
+66 ;; 17. Functional impact
+67 ;;
+68 ;; Does the Veteran's ankle condition impact his or her ability to work?
+69 ;; ___ Yes ___ No
+70 ;; If yes, describe the impact of each of the Veteran's ankle conditions
+71 ;; providing one or more examples: ____________________________________________
+72 ;;^TOF^
+73 ;; 18. Remarks, if any: _______________________________________________________
+74 ;;
+75 ;; Physician signature: ____________________________________ Date: ____________
+76 ;;
+77 ;; Physician printed name: ____________________________________________________
+78 ;;
+79 ;; Medical license #: _________________________________________________________
+80 ;;
+81 ;; Physician address: _________________________________________________________
+82 ;;
+83 ;; Phone: _____________________________ FAX: ______________________________
+84 ;;
+85 ;; NOTE: VA may request additional medical information, including additional
+86 ;; examinations if necessary to complete VA's review of the Veteran's
+87 ;; application.
+88 ;;
+89 ;;^END^
+90 QUIT
