- 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 Feb 18, 2025@23:12:04 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