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Routine: DVBCQAR2

DVBCQAR2.m

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  1. DVBCQAR2 ;;ALB-CIOFO/ECF - NON-DEGERATIVE ARTHRITIS QUESTIONNAIRE ; 6/15/2011
  1. ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
  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
  1. ;; Veteran's claim.
  1. ;; NOTE: Complete this Questionnaire if the Veteran has an inflammatory,
  1. ;; autoimmune, crystalline or infectious arthritis, or dysbaric osteonecrosis
  1. ;; (Caisson disease of bone).
  1. ;; If the Veteran has degenerative arthritis (osteoarthritis) or traumatic
  1. ;; arthritis, do not complete this Questionnaire, INSTEAD complete the joint
  1. ;; Questionnaire for the affected area (e.g., if the diagnosis is
  1. ;; osteoarthritis of the knee, complete the Knee Questionnaire).
  1. ;; If the Veteran has arthritis due to systemic lupus erythematosus (SLE),
  1. ;; instead complete the SLE Questionnaire.
  1. ;;
  1. ;; 1. Diagnosis
  1. ;; Does the Veteran now have or has he/she ever been diagnosed with
  1. ;; inflammatory, autoimmune, crystalline or infectious arthritis or dysbaric
  1. ;; osteonecrosis (Caisson disease)?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, indicate the diagnosis:
  1. ;;
  1. ;; ___ Gout ICD code(s):_______ Date of diagnosis: ________
  1. ;; ___ Rheumatoid arthritis ICD code(s):_______ Date of diagnosis: ________
  1. ;; (atrophic)
  1. ;; ___ Gonorrheal arthritis ICD code(s):_______ Date of diagnosis: ________
  1. ;; ___ Pneumococcic arthritis ICD code(s):_______ Date of diagnosis: ________
  1. ;; ___ Typhoid arthritis ICD code(s): ______ Date of diagnosis: ________
  1. ;; ___ Syphilitic arthritis ICD code(s): ______ Date of diagnosis: ________
  1. ;; ___ Streptococcic arthritis ICD code(s): ______ Date of diagnosis: ________
  1. ;; ___ Dysbaric osteonecrosis) ICD code(s): ______ Date of diagnosis: ________
  1. ;; (Caisson Disease of Bone)
  1. ;; ___ Other
  1. ;; If checked, provide only diagnoses that pertain to inflammatory,
  1. ;; autoimmune, crystalline or infectious arthritis.
  1. ;; Other diagnosis #1: __________________
  1. ;; ICD code: ___________________________
  1. ;; Date of diagnosis: ___________________
  1. ;;
  1. ;; Other diagnosis #2: __________________
  1. ;; ICD code: ___________________________
  1. ;; Date of diagnosis: ___________________
  1. ;;
  1. ;; Other diagnosis #3: __________________
  1. ;; ICD code: ___________________________
  1. ;; Date of diagnosis: ___________________
  1. ;;^TOF^
  1. ;; If there are additional diagnoses that pertain to inflammatory, autoimmune,
  1. ;; crystalline or infectious arthritis, list using above format: ______________
  1. ;;
  1. ;; 2. Medical history
  1. ;; a. Describe history (including onset and course) of the Veteran's
  1. ;; inflammatory, autoimmune, crystalline or infectious arthritis or dysbaric
  1. ;; osteonecrosis (brief summary): _____________________________________________
  1. ;;
  1. ;; b. Does the Veteran require continuous use of medication for this arthritis
  1. ;; condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, list only those medications used for this arthritis: _______________
  1. ;;
  1. ;; c. Has the Veteran lost weight due to this arthritis condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, provide baseline weight (average weight for 2-year period
  1. ;; preceding onset of disease): _____, and current weight: _____.
  1. ;; If yes, does the Veteran's weight loss attributable to this arthritis
  1. ;; condition cause impairment of health?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe the impairment: _________________________________________
  1. ;;
  1. ;; d. Does the Veteran have anemia due to this arthritis condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, does the Veteran's anemia attributable to this arthritis condition
  1. ;; cause impairment of health?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe the impairment (also provide CBC under diagnostic testing
  1. ;; section #9): _______________________________________________________________
  1. ;;
  1. ;; 3. Joint involvement
  1. ;; a. Does the Veteran have pain (with or without joint movement) attributable
  1. ;; to this arthritis condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, indicate affected joints (check all that apply):
  1. ;; ___ Cervical spine ___ Thoracolumbar spine ___ Sacroiliac joints
  1. ;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
  1. ;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
  1. ;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
  1. ;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
  1. ;;
  1. ;; For all checked joints, describe involvement (brief summary): ______________
  1. ;;
  1. ;; ____________________________________________________________________________
  1. ;; Also complete a Questionnaire for each affected joint, if indicated.
  1. ;;^TOF^
  1. ;; b. Does the Veteran have any limitation of joint movement attributable to
  1. ;; this arthritis condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, indicate affected joints (check all that apply):
  1. ;; ___ Cervical spine ___ Thoracolumbar spine ___ Sacroiliac joints
  1. ;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
  1. ;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
  1. ;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
  1. ;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
  1. ;; For all checked joints, describe limitation of movement (brief summary):
  1. ;; ____________________________________________________________________________
  1. ;; Also complete a Questionnaire for each affected joint, if indicated.
  1. ;;
  1. ;; c. Does the Veteran have any joint deformities attributable to this
  1. ;; arthritis condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, indicate affected joints (check all that apply):
  1. ;; ___ Cervical spine ___ Thoracolumbar spine ___ Sacroiliac joints
  1. ;; Right: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
  1. ;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
  1. ;; Left: ___ Shoulder ___ Elbow ___ Wrist ___ Hand/fingers
  1. ;; ___ Hip ___ Knee ___ Ankle ___ Foot/toes
  1. ;; For all checked joints, describe deformities (brief summary): ______________
  1. ;; ____________________________________________________________________________
  1. ;; Also complete a Questionnaire for each affected joint, if indicated.
  1. ;;
  1. ;; 4. Systemic involvement other than joints
  1. ;; Does the Veteran have any involvement of any systems, other than joints,
  1. ;; attributable to this arthritis condition?
  1. ;; ___ Yes ___ No
  1. ;; If yes, indicate systems involved (check all that apply):
  1. ;; ___ Ophthalmological ___ Skin and mucous membranes ___ Hematologic
  1. ;; ___ Pulmonary ___ Cardiac ___ Neurologic ___ Renal ___ Gastrointestinal
  1. ;; ___ Vascular
  1. ;; For all checked systems, describe involvement (brief summary): _____________
  1. ;; ____________________________________________________________________________
  1. ;; Also complete the appropriate Questionnaire if indicated.
  1. ;;^TOF^
  1. ;; 5. Incapacitating and non-incapacitating exacerbations
  1. ;; a. Due to the arthritis condition, does the Veteran have exacerbations
  1. ;; which are not incapacitating?
  1. ;; ___ Yes ___ No
  1. ;; If yes, indicate frequency of non-incapacitating exacerbations per year:
  1. ;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 or more
  1. ;; Date of most recent non-incapacitating exacerbation: _____________________
  1. ;; Duration of most recent non-incapacitating exacerbation: _________________
  1. ;; Describe non-incapacitating exacerbation: ________________________________
  1. ;;
  1. ;; b. Due to the arthritis condition, does the Veteran have exacerbations which
  1. ;; are incapacitating?
  1. ;; ___ Yes ___ No
  1. ;; If yes, describe: __________________________________________________________
  1. ;; Indicate frequency of incapacitating exacerbations per year:
  1. ;; ___ 0 ___ 1 ___ 2 ___ 3 ___ 4 or more
  1. ;; Date of most recent incapacitating exacerbation: _________________________
  1. ;; Duration of most recent incapacitating exacerbation: _____________________
  1. ;; Describe incapacitating exacerbation: ____________________________________
  1. ;;
  1. ;; c. Due to the arthritis condition, does the Veteran have constitutional
  1. ;; manifestations associated with active joint involvement which are totally
  1. ;; incapacitating?
  1. ;; ___ Yes ___ No
  1. ;; If yes, has the Veteran been totally incapacitated due to this during the
  1. ;; past 12 months?
  1. ;; ___ Yes ___ No
  1. ;; If yes indicate the total duration of incapacitation over the past 12
  1. ;; months:
  1. ;; ___ < 1 week
  1. ;; ___ 1 week to < 2 weeks
  1. ;; ___ 2 weeks to < 4 weeks
  1. ;; ___ 4 weeks to < 6 weeks
  1. ;; ___ 6 weeks or more
  1. ;; Describe constitutional manifestations and the manner in which those
  1. ;; manifestations cause incapacitation: _______________________________________
  1. ;;
  1. ;; 6. Other pertinent physical findings, complications, conditions, signs
  1. ;; and/or symptoms
  1. ;; a. Does the Veteran have any scars (surgical or otherwise) related to
  1. ;; any 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. ;;^TOF^
  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. ;; 7. Assistive devices
  1. ;; a. Does the Veteran use any assistive device(s) as a normal mode of
  1. ;; locomotion, although occasional locomotion by other methods may be possible?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, identify assistive device(s) used (check all that apply and indicate
  1. ;; frequency):
  1. ;; __ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
  1. ;; __ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
  1. ;; __ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
  1. ;; __ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
  1. ;; __ Walker Frequency of use: __ Occasional __ Regular __ Constant
  1. ;; __ Other: ________________________________________________________________
  1. ;; Frequency of use: __ Occasional __ Regular __ Constant
  1. ;;
  1. ;; b. If the Veteran uses any assistive devices, specify the condition and
  1. ;; identify the assistive device used for each condition: _____________________
  1. ;;
  1. ;; 8. Remaining effective function of the extremities
  1. ;; Due to the Veteran's inflammatory, autoimmune, crystalline or infectious
  1. ;; arthritis or dysbaric osteonecrosis, is there functional impairment of an
  1. ;; extremity such that no effective function remains other than that which
  1. ;; would be equally well served by an amputation with prosthesis? (Functions
  1. ;; of the upper extremity include grasping, manipulation, etc., while functions
  1. ;; for the lower extremity include balance and propulsion, etc.)
  1. ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
  1. ;; equally serve the Veteran.
  1. ;; ___ No
  1. ;; If yes, indicate extremities for which this applies:
  1. ;; ___ Right upper ___ Left upper ___ Right lower ___ Left lower
  1. ;;
  1. ;; For each checked extremity, identify the condition causing loss of function,
  1. ;; describe loss of effective function and provide specific examples (brief
  1. ;; summary): __________________________________________________________________
  1. ;;
  1. Q