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Routine: DVBCQBK2

DVBCQBK2.m

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DVBCQBK2 ;;ALB-CIOFO/ECF - BACK (THORACOLUMBAR SPINE) QUESTIONNAIRE ; 5/15/2011

 ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1

 ;

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 been diagnosed with a

 ;; thoracolumbar spine (back) condition?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, provide only diagnoses that pertain to thoracolumbar spine (back)

 ;; conditions:

 ;;

 ;;     Diagnosis #1: ____________________

 ;;     ICD code: ________________________

 ;;     Date of diagnosis: _______________

 ;;

 ;;     Diagnosis #2: ____________________

 ;;     ICD code: ________________________

 ;;     Date of diagnosis: _______________

 ;;

 ;;     Diagnosis #3: ____________________

 ;;     ICD code: ________________________

 ;;     Date of diagnosis: _______________

 ;;

 ;; If there are additional diagnoses pertaining to thoracolumbar spine (back)

 ;; conditions, list using above format: _______________________________________

 ;;

 ;; 2. Medical history

 ;;

 ;; Describe the history (including onset and course) of the Veteran's

 ;; thoracolumbar spine (back) condition (brief summary): ______________________

 ;;

 ;; 3. Flare-ups

 ;;

 ;; Does the Veteran report that flare-ups impact the function of the

 ;; thoracolumbar spine (back)?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, document the Veteran's description of the impact of flare-ups in his

 ;; or her own words: __________________________________________________________

 ;;^TOF^

 ;; 4. Initial range of motion (ROM) measurements:

 ;;

 ;; Measure ROM with a goniometer, rounding each measurement to the nearest 5

 ;; degrees. During the measurements, observe the point at which painful

 ;; motion begins, evidenced by visible behavior such as facial expression,

 ;; wincing, etc.  Report initial measurements below.

 ;;

 ;; Following the initial assessment of ROM, perform repetitive-use testing.

 ;; For VA purposes, repetitive-use testing must be included in all exams. The

 ;; VA has determined that 3 repetitions of ROM (at 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. Select where forward flexion ends (normal endpoint is 90):

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30  __ 35   __ 40   __ 45

 ;; __ 50  __ 55  __ 60   __ 65   __ 70   __ 75   __ 80  __ 85   __ 90 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

 ;; __ 50  __ 55  __ 60   __ 65   __ 70   __ 75   __ 80  __ 85   __ 90 or greater

 ;;

 ;; b. Select where extension ends (normal endpoint is 30):

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; Select where objective evidence of painful motion begins:

 ;; __ No objective evidence of painful motion

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; c. Select where right lateral flexion ends (normal endpoint is 30):

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; Select where objective evidence of painful motion begins:

 ;; __ No objective evidence of painful motion

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; d. Select where left lateral flexion ends (normal endpoint is 30):

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; Select where objective evidence of painful motion begins:

 ;; __ No objective evidence of painful motion

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;^TOF^

 ;; e. Select where right lateral rotation ends (normal endpoint is 30):

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; Select where objective evidence of painful motion begins:

 ;; __ No  objective evidence of painful motion

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; f. Select where left lateral rotation ends (normal endpoint is 30):

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; Select where objective evidence of painful motion begins:

 ;; __ No objective evidence of painful motion

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; g. If ROM for this Veteran does not conform to the normal range of motion

 ;; identified above but is normal for this Veteran (for reasons other than a

 ;; back condition, such as age, body habitus, neurologic disease), explain:

 ;;_____________________________________________________________________________

 ;;

 ;; 5. ROM measurements after repetitive-use testing

 ;;

 ;; a. Is 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. Select where post-test forward flexion ends:

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30   __ 35  __ 40   __ 45

 ;; __ 50  __ 55  __ 60   __ 65   __ 70   __ 75   __ 80   __ 85  __ 90 or greater

 ;;

 ;; c. Select where post-test extension ends:

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; d. Select where post-test right lateral flexion ends:

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; e. Select where post-test left lateral flexion ends:

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; f. Select where post-test right lateral rotation ends:

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;

 ;; g. Select where post-test left lateral rotation ends:

 ;; __ 0   __ 5   __ 10   __ 15   __ 20   __ 25   __ 30 or greater

 ;;^TOF^

 ;; 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 thoracolumbar

 ;; spine (back) following repetitive-use testing?

 ;; ___ Yes   ___ No

 ;;

 ;; b. Does the Veteran have any functional loss and/or functional impairment of

 ;; the thoracolumbar spine (back)?

 ;; ___ Yes   ___ No

 ;;

 ;; c. If the Veteran has functional loss, functional impairment and/or

 ;; additional limitation of ROM of the thoracolumbar spine (back) after

 ;; repetitive use, indicate the contributing factors of disability below:

 ;;

 ;;    ___ Less movement than normal

 ;;    ___ More movement than normal

 ;;    ___ Weakened movement

 ;;    ___ Excess fatigability

 ;;    ___ Incoordination, impaired ability to execute skilled movements smoothly

 ;;    ___ Pain on movement

 ;;    ___ Swelling

 ;;    ___ Deformity

 ;;    ___ Atrophy of disuse

 ;;    ___ Instability of station

 ;;    ___ Disturbance of locomotion

 ;;    ___ Interference with sitting, standing and/or weight-bearing

 ;;    ___ Other, describe: ____________________________________________________

 ;;

 ;; 7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait)

 ;;

 ;; a. Does the Veteran have localized tenderness or pain to palpation for

 ;; joints and/or soft tissue of the thoracolumbar spine (back)?

 ;; ___ Yes   ___ No

 ;; If yes, describe: __________________________________________________________

 ;;^TOF^

 ;; b. Does the Veteran have guarding or muscle spasm of the thoracolumbar spine

 ;; (back)?

 ;; ___ Yes   ___ No

 ;; 

 ;; If yes, is it severe enough to result in: (check all that apply)

 ;;    ___ Abnormal gait

 ;;    ___ Abnormal spinal contour, such as scoliosis, reversed lordosis, or

 ;;        abnormal kyphosis

 ;;    ___ Guarding and/or muscle spasm is present, but do not result in

 ;;        abnormal gait or spinal contour

 ;;

 ;; 8. Muscle strength testing

 ;;

 ;; a. 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

 ;;

 ;;    ___ All normal

 ;;

 ;;    Hip 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

 ;;    Knee extension:

 ;;             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 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

 ;;    Great toe extension:

 ;;             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

 ;;

 ;; b. Does the Veteran have muscle atrophy?

 ;; ___ Yes   ___ No

 ;;

 ;; If muscle atrophy is present, indicate location: ___________________________

 ;; Provide measurements in centimeters of normal side and atrophied side,

 ;; measured at maximum muscle bulk:

 ;;    Normal side: _____ cm.     Atrophied side: _____ cm.

 ;;^TOF^

 ;; 9. Reflex exam

 ;;

 ;; Rate deep tendon reflexes (DTRs) according to the following scale:

 ;;    0  Absent

 ;;    1+ Hypoactive

 ;;    2+ Normal

 ;;    3+ Hyperactive without clonus

 ;;    4+ Hyperactive with clonus

 ;;

 ;; ___ All normal

 ;;

 ;; Knee:   Right:   ___0   ___ 1+   ___ 2+   ___ 3+   ___ 4+

 ;;         Left:    ___0   ___ 1+   ___ 2+   ___ 3+   ___ 4+

 ;;

 ;; Ankle:  Right:   ___0   ___ 1+   ___ 2+   ___ 3+   ___ 4+

 ;;         Left:    ___0   ___ 1+   ___ 2+   ___ 3+   ___ 4+

 ;;

 ;; 10. Sensory exam

 ;;

 ;; Provide results for sensation to light touch (dermatomes) testing:

 ;;

 ;; ___ All normal

 ;;

 ;; Upper anterior thigh (L2):

 ;;        Right:   ___ Normal   ___ Decreased   ___ Absent

 ;;        Left:    ___ Normal   ___ Decreased   ___ Absent

 ;;

 ;; Thigh/knee (L3/4):

 ;;        Right:   ___ Normal   ___ Decreased   ___ Absent

 ;;        Left:    ___ Normal   ___ Decreased   ___ Absent

 ;;

 ;; Lower leg/ankle (L4/L5/S1):

 ;;        Right:   ___ Normal   ___ Decreased   ___ Absent

 ;;        Left:    ___ Normal   ___ Decreased   ___ Absent

 ;; Foot/toes (L5):

 ;;        Right:   ___ Normal   ___ Decreased   ___ Absent

 ;;        Left:    ___ Normal   ___ Decreased   ___ Absent

 ;;

 ;; Other sensory findings, if any: ____________________________________________

 ;;

 Q