DVBCQAR2 ;;ALB-CIOFO/ECF - NON-DEGERATIVE ARTHRITIS QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;**174**;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: Complete this Questionnaire if the Veteran has an inflammatory,
;; autoimmune, crystalline or infectious arthritis, or dysbaric osteonecrosis
;; (Caisson disease of bone).
;; If the Veteran has degenerative arthritis (osteoarthritis) or traumatic
;; arthritis, do not complete this Questionnaire, INSTEAD complete the joint
;; Questionnaire for the affected area (e.g., if the diagnosis is
;; osteoarthritis of the knee, complete the Knee Questionnaire).
;; If the Veteran has arthritis due to systemic lupus erythematosus (SLE),
;; instead complete the SLE Questionnaire.
;;
;; 1. Diagnosis
;; Does the Veteran now have or has he/she ever been diagnosed with
;; inflammatory, autoimmune, crystalline or infectious arthritis or dysbaric
;; osteonecrosis (Caisson disease)?
;; ___ Yes ___ No
;;
;; If yes, indicate the diagnosis:
;;
;; ___ Gout ICD code(s):_______ Date of diagnosis: ________
;; ___ Rheumatoid arthritis ICD code(s):_______ Date of diagnosis: ________
;; (atrophic)
;; ___ Gonorrheal arthritis ICD code(s):_______ Date of diagnosis: ________
;; ___ Pneumococcic arthritis ICD code(s):_______ Date of diagnosis: ________
;; ___ Typhoid arthritis ICD code(s): ______ Date of diagnosis: ________
;; ___ Syphilitic arthritis ICD code(s): ______ Date of diagnosis: ________
;; ___ Streptococcic arthritis ICD code(s): ______ Date of diagnosis: ________
;; ___ Dysbaric osteonecrosis) ICD code(s): ______ Date of diagnosis: ________
;; (Caisson Disease of Bone)
;; ___ Other
;; If checked, provide only diagnoses that pertain to inflammatory,
;; autoimmune, crystalline or infectious arthritis.
;; Other diagnosis #1: __________________
;; ICD code: ___________________________
;; Date of diagnosis: ___________________
;;
;; Other diagnosis #2: __________________
;; ICD code: ___________________________
;; Date of diagnosis: ___________________
;;
;; Other diagnosis #3: __________________
;; ICD code: ___________________________
;; Date of diagnosis: ___________________
;;^TOF^
;; If there are additional diagnoses that pertain to inflammatory, autoimmune,
;; crystalline or infectious arthritis, list using above format: ______________
;;
;; 2. Medical history
;; a. Describe history (including onset and course) of the Veteran's
;; inflammatory, autoimmune, crystalline or infectious arthritis or dysbaric
;; osteonecrosis (brief summary): _____________________________________________
;;
;; b. Does the Veteran require continuous use of medication for this arthritis
;; condition?
;; ___ Yes ___ No
;; If yes, list only those medications used for this arthritis: _______________
;;
;; c. Has the Veteran lost weight due to this arthritis condition?
;; ___ Yes ___ No
;; If yes, provide baseline weight (average weight for 2-year period
;; preceding onset of disease): _____, and current weight: _____.
;; If yes, does the Veteran's weight loss attributable to this arthritis
;; condition cause impairment of health?
;; ___ Yes ___ No
;; If yes, describe the impairment: _________________________________________
;;
;; d. Does the Veteran have anemia due to this arthritis condition?
;; ___ Yes ___ No
;; If yes, does the Veteran's anemia attributable to this arthritis condition
;; cause impairment of health?
;; ___ Yes ___ No
;; If yes, describe the impairment (also provide CBC under diagnostic testing
;; section #9): _______________________________________________________________
;;
;; 3. Joint involvement
;; a. Does the Veteran have pain (with or without joint movement) attributable
;; to this arthritis condition?
;; ___ Yes ___ No
;; If yes, indicate affected joints (check all that apply):
;; ___ Cervical spine ___ Thoracolumbar spine ___ Sacroiliac joints
;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
;;
;; For all checked joints, describe involvement (brief summary): ______________
;;
;; ____________________________________________________________________________
;; Also complete a Questionnaire for each affected joint, if indicated.
;;^TOF^
;; b. Does the Veteran have any limitation of joint movement attributable to
;; this arthritis condition?
;; ___ Yes ___ No
;; If yes, indicate affected joints (check all that apply):
;; ___ Cervical spine ___ Thoracolumbar spine ___ Sacroiliac joints
;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
;; For all checked joints, describe limitation of movement (brief summary):
;; ____________________________________________________________________________
;; Also complete a Questionnaire for each affected joint, if indicated.
;;
;; c. Does the Veteran have any joint deformities attributable to this
;; arthritis condition?
;; ___ Yes ___ No
;; If yes, indicate affected joints (check all that apply):
;; ___ Cervical spine ___ Thoracolumbar spine ___ Sacroiliac joints
;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
;; For all checked joints, describe deformities (brief summary): ______________
;; ____________________________________________________________________________
;; Also complete a Questionnaire for each affected joint, if indicated.
;;
;; 4. Systemic involvement other than joints
;; Does the Veteran have any involvement of any systems, other than joints,
;; attributable to this arthritis condition?
;; ___ Yes ___ No
;; If yes, indicate systems involved (check all that apply):
;; ___ Ophthalmological ___ Skin and mucous membranes ___ Hematologic
;; ___ Pulmonary ___ Cardiac ___ Neurologic ___ Renal ___ Gastrointestinal
;; ___ Vascular
;; For all checked systems, describe involvement (brief summary): _____________
;; ____________________________________________________________________________
;; Also complete the appropriate Questionnaire if indicated.
;;^TOF^
;; 5. Incapacitating and non-incapacitating exacerbations
;; a. Due to the arthritis condition, does the Veteran have exacerbations
;; which are not incapacitating?
;; ___ Yes ___ No
;; If yes, indicate frequency of non-incapacitating exacerbations per year:
;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 or more
;; Date of most recent non-incapacitating exacerbation: _____________________
;; Duration of most recent non-incapacitating exacerbation: _________________
;; Describe non-incapacitating exacerbation: ________________________________
;;
;; b. Due to the arthritis condition, does the Veteran have exacerbations which
;; are incapacitating?
;; ___ Yes ___ No
;; If yes, describe: __________________________________________________________
;; Indicate frequency of incapacitating exacerbations per year:
;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 or more
;; Date of most recent incapacitating exacerbation: _________________________
;; Duration of most recent incapacitating exacerbation: _____________________
;; Describe incapacitating exacerbation: ____________________________________
;;
;; c. Due to the arthritis condition, does the Veteran have constitutional
;; manifestations associated with active joint involvement which are totally
;; incapacitating?
;; ___ Yes ___ No
;; If yes, has the Veteran been totally incapacitated due to this during the
;; past 12 months?
;; ___ Yes ___ No
;; If yes indicate the total duration of incapacitation over the past 12
;; months:
;; ___ < 1 week
;; ___ 1 week to < 2 weeks
;; ___ 2 weeks to < 4 weeks
;; ___ 4 weeks to < 6 weeks
;; ___ 6 weeks or more
;; Describe constitutional manifestations and the manner in which those
;; manifestations cause incapacitation: _______________________________________
;;
;; 6. 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.
;;^TOF^
;; 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): __________________________________________
;;
;; 7. 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: _____________________
;;
;; 8. Remaining effective function of the extremities
;; Due to the Veteran's inflammatory, autoimmune, crystalline or infectious
;; arthritis or dysbaric osteonecrosis, 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 upper ___ Left upper ___ 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): __________________________________________________________________
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQAR2 11849 printed Apr 09, 2024@20:54:49 Page 2
DVBCQAR2 ;;ALB-CIOFO/ECF - NON-DEGERATIVE ARTHRITIS QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+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
+5 ;; Veteran's claim.
+6 ;; NOTE: Complete this Questionnaire if the Veteran has an inflammatory,
+7 ;; autoimmune, crystalline or infectious arthritis, or dysbaric osteonecrosis
+8 ;; (Caisson disease of bone).
+9 ;; If the Veteran has degenerative arthritis (osteoarthritis) or traumatic
+10 ;; arthritis, do not complete this Questionnaire, INSTEAD complete the joint
+11 ;; Questionnaire for the affected area (e.g., if the diagnosis is
+12 ;; osteoarthritis of the knee, complete the Knee Questionnaire).
+13 ;; If the Veteran has arthritis due to systemic lupus erythematosus (SLE),
+14 ;; instead complete the SLE Questionnaire.
+15 ;;
+16 ;; 1. Diagnosis
+17 ;; Does the Veteran now have or has he/she ever been diagnosed with
+18 ;; inflammatory, autoimmune, crystalline or infectious arthritis or dysbaric
+19 ;; osteonecrosis (Caisson disease)?
+20 ;; ___ Yes ___ No
+21 ;;
+22 ;; If yes, indicate the diagnosis:
+23 ;;
+24 ;; ___ Gout ICD code(s):_______ Date of diagnosis: ________
+25 ;; ___ Rheumatoid arthritis ICD code(s):_______ Date of diagnosis: ________
+26 ;; (atrophic)
+27 ;; ___ Gonorrheal arthritis ICD code(s):_______ Date of diagnosis: ________
+28 ;; ___ Pneumococcic arthritis ICD code(s):_______ Date of diagnosis: ________
+29 ;; ___ Typhoid arthritis ICD code(s): ______ Date of diagnosis: ________
+30 ;; ___ Syphilitic arthritis ICD code(s): ______ Date of diagnosis: ________
+31 ;; ___ Streptococcic arthritis ICD code(s): ______ Date of diagnosis: ________
+32 ;; ___ Dysbaric osteonecrosis) ICD code(s): ______ Date of diagnosis: ________
+33 ;; (Caisson Disease of Bone)
+34 ;; ___ Other
+35 ;; If checked, provide only diagnoses that pertain to inflammatory,
+36 ;; autoimmune, crystalline or infectious arthritis.
+37 ;; Other diagnosis #1: __________________
+38 ;; ICD code: ___________________________
+39 ;; Date of diagnosis: ___________________
+40 ;;
+41 ;; Other diagnosis #2: __________________
+42 ;; ICD code: ___________________________
+43 ;; Date of diagnosis: ___________________
+44 ;;
+45 ;; Other diagnosis #3: __________________
+46 ;; ICD code: ___________________________
+47 ;; Date of diagnosis: ___________________
+48 ;;^TOF^
+49 ;; If there are additional diagnoses that pertain to inflammatory, autoimmune,
+50 ;; crystalline or infectious arthritis, list using above format: ______________
+51 ;;
+52 ;; 2. Medical history
+53 ;; a. Describe history (including onset and course) of the Veteran's
+54 ;; inflammatory, autoimmune, crystalline or infectious arthritis or dysbaric
+55 ;; osteonecrosis (brief summary): _____________________________________________
+56 ;;
+57 ;; b. Does the Veteran require continuous use of medication for this arthritis
+58 ;; condition?
+59 ;; ___ Yes ___ No
+60 ;; If yes, list only those medications used for this arthritis: _______________
+61 ;;
+62 ;; c. Has the Veteran lost weight due to this arthritis condition?
+63 ;; ___ Yes ___ No
+64 ;; If yes, provide baseline weight (average weight for 2-year period
+65 ;; preceding onset of disease): _____, and current weight: _____.
+66 ;; If yes, does the Veteran's weight loss attributable to this arthritis
+67 ;; condition cause impairment of health?
+68 ;; ___ Yes ___ No
+69 ;; If yes, describe the impairment: _________________________________________
+70 ;;
+71 ;; d. Does the Veteran have anemia due to this arthritis condition?
+72 ;; ___ Yes ___ No
+73 ;; If yes, does the Veteran's anemia attributable to this arthritis condition
+74 ;; cause impairment of health?
+75 ;; ___ Yes ___ No
+76 ;; If yes, describe the impairment (also provide CBC under diagnostic testing
+77 ;; section #9): _______________________________________________________________
+78 ;;
+79 ;; 3. Joint involvement
+80 ;; a. Does the Veteran have pain (with or without joint movement) attributable
+81 ;; to this arthritis condition?
+82 ;; ___ Yes ___ No
+83 ;; If yes, indicate affected joints (check all that apply):
+84 ;; ___ Cervical spine ___ Thoracolumbar spine ___ Sacroiliac joints
+85 ;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
+86 ;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
+87 ;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
+88 ;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
+89 ;;
+90 ;; For all checked joints, describe involvement (brief summary): ______________
+91 ;;
+92 ;; ____________________________________________________________________________
+93 ;; Also complete a Questionnaire for each affected joint, if indicated.
+94 ;;^TOF^
+95 ;; b. Does the Veteran have any limitation of joint movement attributable to
+96 ;; this arthritis condition?
+97 ;; ___ Yes ___ No
+98 ;; If yes, indicate affected joints (check all that apply):
+99 ;; ___ Cervical spine ___ Thoracolumbar spine ___ Sacroiliac joints
+100 ;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
+101 ;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
+102 ;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
+103 ;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
+104 ;; For all checked joints, describe limitation of movement (brief summary):
+105 ;; ____________________________________________________________________________
+106 ;; Also complete a Questionnaire for each affected joint, if indicated.
+107 ;;
+108 ;; c. Does the Veteran have any joint deformities attributable to this
+109 ;; arthritis condition?
+110 ;; ___ Yes ___ No
+111 ;; If yes, indicate affected joints (check all that apply):
+112 ;; ___ Cervical spine ___ Thoracolumbar spine ___ Sacroiliac joints
+113 ;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
+114 ;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
+115 ;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
+116 ;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
+117 ;; For all checked joints, describe deformities (brief summary): ______________
+118 ;; ____________________________________________________________________________
+119 ;; Also complete a Questionnaire for each affected joint, if indicated.
+120 ;;
+121 ;; 4. Systemic involvement other than joints
+122 ;; Does the Veteran have any involvement of any systems, other than joints,
+123 ;; attributable to this arthritis condition?
+124 ;; ___ Yes ___ No
+125 ;; If yes, indicate systems involved (check all that apply):
+126 ;; ___ Ophthalmological ___ Skin and mucous membranes ___ Hematologic
+127 ;; ___ Pulmonary ___ Cardiac ___ Neurologic ___ Renal ___ Gastrointestinal
+128 ;; ___ Vascular
+129 ;; For all checked systems, describe involvement (brief summary): _____________
+130 ;; ____________________________________________________________________________
+131 ;; Also complete the appropriate Questionnaire if indicated.
+132 ;;^TOF^
+133 ;; 5. Incapacitating and non-incapacitating exacerbations
+134 ;; a. Due to the arthritis condition, does the Veteran have exacerbations
+135 ;; which are not incapacitating?
+136 ;; ___ Yes ___ No
+137 ;; If yes, indicate frequency of non-incapacitating exacerbations per year:
+138 ;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 or more
+139 ;; Date of most recent non-incapacitating exacerbation: _____________________
+140 ;; Duration of most recent non-incapacitating exacerbation: _________________
+141 ;; Describe non-incapacitating exacerbation: ________________________________
+142 ;;
+143 ;; b. Due to the arthritis condition, does the Veteran have exacerbations which
+144 ;; are incapacitating?
+145 ;; ___ Yes ___ No
+146 ;; If yes, describe: __________________________________________________________
+147 ;; Indicate frequency of incapacitating exacerbations per year:
+148 ;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 or more
+149 ;; Date of most recent incapacitating exacerbation: _________________________
+150 ;; Duration of most recent incapacitating exacerbation: _____________________
+151 ;; Describe incapacitating exacerbation: ____________________________________
+152 ;;
+153 ;; c. Due to the arthritis condition, does the Veteran have constitutional
+154 ;; manifestations associated with active joint involvement which are totally
+155 ;; incapacitating?
+156 ;; ___ Yes ___ No
+157 ;; If yes, has the Veteran been totally incapacitated due to this during the
+158 ;; past 12 months?
+159 ;; ___ Yes ___ No
+160 ;; If yes indicate the total duration of incapacitation over the past 12
+161 ;; months:
+162 ;; ___ < 1 week
+163 ;; ___ 1 week to < 2 weeks
+164 ;; ___ 2 weeks to < 4 weeks
+165 ;; ___ 4 weeks to < 6 weeks
+166 ;; ___ 6 weeks or more
+167 ;; Describe constitutional manifestations and the manner in which those
+168 ;; manifestations cause incapacitation: _______________________________________
+169 ;;
+170 ;; 6. Other pertinent physical findings, complications, conditions, signs
+171 ;; and/or symptoms
+172 ;; a. Does the Veteran have any scars (surgical or otherwise) related to
+173 ;; any conditions or to the treatment of any conditions listed in the Diagnosis
+174 ;; section above?
+175 ;; ___ Yes ___ No
+176 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+177 ;; of all related scars greater than 39 square cm (6 square inches)?
+178 ;; ___ Yes ___ No
+179 ;; If yes, also complete a Scars Questionnaire.
+180 ;;^TOF^
+181 ;; b. Does the Veteran have any other pertinent physical findings,
+182 ;; complications, conditions, signs and/or symptoms related to any conditions
+183 ;; listed in the Diagnosis section above?
+184 ;; ___ Yes ___ No
+185 ;; If yes, describe (brief summary): __________________________________________
+186 ;;
+187 ;; 7. Assistive devices
+188 ;; a. Does the Veteran use any assistive device(s) as a normal mode of
+189 ;; locomotion, although occasional locomotion by other methods may be possible?
+190 ;; ___ Yes ___ No
+191 ;;
+192 ;; If yes, identify assistive device(s) used (check all that apply and indicate
+193 ;; frequency):
+194 ;; __ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
+195 ;; __ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
+196 ;; __ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
+197 ;; __ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
+198 ;; __ Walker Frequency of use: __ Occasional __ Regular __ Constant
+199 ;; __ Other: ________________________________________________________________
+200 ;; Frequency of use: __ Occasional __ Regular __ Constant
+201 ;;
+202 ;; b. If the Veteran uses any assistive devices, specify the condition and
+203 ;; identify the assistive device used for each condition: _____________________
+204 ;;
+205 ;; 8. Remaining effective function of the extremities
+206 ;; Due to the Veteran's inflammatory, autoimmune, crystalline or infectious
+207 ;; arthritis or dysbaric osteonecrosis, is there functional impairment of an
+208 ;; extremity such that no effective function remains other than that which
+209 ;; would be equally well served by an amputation with prosthesis? (Functions
+210 ;; of the upper extremity include grasping, manipulation, etc., while functions
+211 ;; for the lower extremity include balance and propulsion, etc.)
+212 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+213 ;; equally serve the Veteran.
+214 ;; ___ No
+215 ;; If yes, indicate extremities for which this applies:
+216 ;; ___ Right upper ___ Left upper ___ Right lower ___ Left lower
+217 ;;
+218 ;; For each checked extremity, identify the condition causing loss of function,
+219 ;; describe loss of effective function and provide specific examples (brief
+220 ;; summary): __________________________________________________________________
+221 ;;
+222 QUIT
