DVBCQBK3 ;;ALB-CIOFO/ECF - BACK (THORACOLUMBAR SPINE) QUESTIONNAIRE ; 5/15/2011
;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
;
TXT ;
;;
;;^TOF^
;; 11. Straight leg raising test
;;
;; (This test can be performed with the Veteran seated or supine. Raise each
;; straightened leg until pain begins, typically at 30-70 degrees of elevation.
;; The test is positive if the pain radiates below the knee, not merely in the
;; back or hamstrings. Pain is often increased on dorsiflexion of the foot,
;; and relieved by knee flexion. A positive test suggests radiculopathy, often
;; due to disc herniation).
;;
;; Provide straight leg raising test results:
;; Right: ___ Negative ___ Positive ___ Unable to perform
;; Left: ___ Negative ___ Positive ___ Unable to perform
;;
;; 12. Radiculopathy
;;
;; Does the Veteran have radicular pain or any other signs or symptoms
;; due to radiculopathy?
;; ___ Yes ___ No
;; If yes, complete the following section:
;;
;; a. Indicate symptoms' location and severity (check all that apply):
;;
;; Constant pain (may be excruciating at times)
;; Right lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
;; Left lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
;;
;; Intermittent pain (usually dull)
;; Right lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
;; Left lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
;;
;; Paresthesias and/or dysesthesias
;; Right lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
;; Left lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
;;
;; Numbness
;; Right lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
;; Left lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
;;
;; b. Does the Veteran have any other signs or symptoms of radiculopathy?
;; ___ Yes ___ No
;;
;; If yes, describe: __________________________________________________________
;;^TOF^
;; c. Indicate nerve roots involved: (check all that apply)
;;
;; ___ Involvement of L2/L3L/L4 nerve roots (femoral nerve)
;; If checked, indicate: ___ Right ___ Left ___ Both
;; ___ Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)
;; If checked, indicate: ___ Right ___ Left ___ Both
;; ___ Other nerves (specify nerve and side(s) affected): _____________________
;;
;; d. Indicate severity of radiculopathy and side affected:
;;
;; Right: ___ Not affected ___ Mild ___ Moderate ___ Severe
;; Left: ___ Not affected ___ Mild ___ Moderate ___ Severe
;;
;; 13. Other neurologic abnormalities
;;
;; Does the Veteran have any other neurologic abnormalities or findings related
;; to a thoracolumbar spine (back) condition (such as bowel or bladder
;; problems/pathologic reflexes)?
;; ___ Yes ___ No
;;
;; If yes, describe condition and how it is related: __________________________
;;
;; If there are neurological abnormalities other than radiculopathy, also
;; complete appropriate Questionnaire for each condition identified.
;;
;; 14. Intervertebral disc syndrome (IVDS) and incapacitating episodes
;;
;; a. Does the Veteran have IVDS of the thoracolumbar spine?
;; ___ Yes ___ No
;;
;; b. If yes, has the Veteran had any incapacitating episodes over the past 12
;; months due to IVDS?
;; ___ Yes ___ No
;;
;; NOTE: For VA purposes, an incapacitating episode is a period of acute
;; symptoms severe enough to require prescribed bed rest and treatment by a
;; physician.
;;
;; If yes, provide the total duration of all incapacitating episodes over the
;; past 12 months:
;; ___ Less than 1 week
;; ___ At least 1 week but less than 2 weeks
;; ___ At least 2 weeks but less than 4 weeks
;; ___ At least 4 weeks but less than 6 weeks
;; ___ At least 6 weeks
;;^TOF^
;; 15. 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: _____________________
;; ____________________________________________________________________________
;;
;; 16. Remaining effective function of the extremities
;;
;; Due to a thoracolumbar spine (back) condition, 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.; functions of 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 extremity(ies) (check all extremities for which this
;; applies):
;; ___ Right lower ___ Left lower
;;^TOF^
;; 17. 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.
;;
;; b. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs or symptoms?
;; ___ Yes ___ No
;;
;; If yes, describe (brief summary)____________________________________________
;;
;; 18. Diagnostic testing
;;
;; The diagnosis of arthritis must be confirmed by imaging studies. Once
;; arthritis has been documented, no further imaging studies are required by
;; VA, even if arthritis has worsened.
;;
;; Imaging studies are not required to make the diagnosis of IVDS;
;; Electromyography (EMG) studies are rarely required to diagnose radiculopathy
;; in the appropriate clinical setting.
;;
;; For purposes of this examination, the diagnosis of IVDS and/or radiculopathy
;; can be made by a history of characteristic radiating pain and/or sensory
;; changes in the legs, and objective clinical findings, which may include the
;; asymmetrical loss or decrease of reflexes, decreased strength and/or
;; abnormal sensation.
;;
;; a. Have imaging studies of the thoracolumbar spine been performed and are
;; the results available?
;; ___ Yes ___ No
;;
;; If yes, is arthritis documented?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have a vertebral fracture?
;; ___ Yes ___ No
;;
;; If yes, provide percent of loss of vertebral body: ____________
;;^TOF^
;; c. 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):
;; ____________________________________________________________________________
;;
;; 19. Functional impact
;;
;; Does the Veteran's thoracolumbar spine (back) condition impact his or her
;; ability to work?
;; ___ Yes ___ No
;;
;; If yes describe the impact of each of the Veteran's thoracolumbar spine
;; (back) conditions providing one or more examples ___________________________
;;
;;_____________________________________________________________________________
;;
;; 20. 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[HDVBCQBK3 9319 printed Apr 09, 2024@20:53:23 Page 2
DVBCQBK3 ;;ALB-CIOFO/ECF - BACK (THORACOLUMBAR SPINE) QUESTIONNAIRE ; 5/15/2011
+1 ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
+2 ;
TXT ;
+1 ;;
+2 ;;^TOF^
+3 ;; 11. Straight leg raising test
+4 ;;
+5 ;; (This test can be performed with the Veteran seated or supine. Raise each
+6 ;; straightened leg until pain begins, typically at 30-70 degrees of elevation.
+7 ;; The test is positive if the pain radiates below the knee, not merely in the
+8 ;; back or hamstrings. Pain is often increased on dorsiflexion of the foot,
+9 ;; and relieved by knee flexion. A positive test suggests radiculopathy, often
+10 ;; due to disc herniation).
+11 ;;
+12 ;; Provide straight leg raising test results:
+13 ;; Right: ___ Negative ___ Positive ___ Unable to perform
+14 ;; Left: ___ Negative ___ Positive ___ Unable to perform
+15 ;;
+16 ;; 12. Radiculopathy
+17 ;;
+18 ;; Does the Veteran have radicular pain or any other signs or symptoms
+19 ;; due to radiculopathy?
+20 ;; ___ Yes ___ No
+21 ;; If yes, complete the following section:
+22 ;;
+23 ;; a. Indicate symptoms' location and severity (check all that apply):
+24 ;;
+25 ;; Constant pain (may be excruciating at times)
+26 ;; Right lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
+27 ;; Left lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
+28 ;;
+29 ;; Intermittent pain (usually dull)
+30 ;; Right lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
+31 ;; Left lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
+32 ;;
+33 ;; Paresthesias and/or dysesthesias
+34 ;; Right lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
+35 ;; Left lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
+36 ;;
+37 ;; Numbness
+38 ;; Right lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
+39 ;; Left lower extremity: ___ None ___ Mild ___ Moderate ___ Severe
+40 ;;
+41 ;; b. Does the Veteran have any other signs or symptoms of radiculopathy?
+42 ;; ___ Yes ___ No
+43 ;;
+44 ;; If yes, describe: __________________________________________________________
+45 ;;^TOF^
+46 ;; c. Indicate nerve roots involved: (check all that apply)
+47 ;;
+48 ;; ___ Involvement of L2/L3L/L4 nerve roots (femoral nerve)
+49 ;; If checked, indicate: ___ Right ___ Left ___ Both
+50 ;; ___ Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)
+51 ;; If checked, indicate: ___ Right ___ Left ___ Both
+52 ;; ___ Other nerves (specify nerve and side(s) affected): _____________________
+53 ;;
+54 ;; d. Indicate severity of radiculopathy and side affected:
+55 ;;
+56 ;; Right: ___ Not affected ___ Mild ___ Moderate ___ Severe
+57 ;; Left: ___ Not affected ___ Mild ___ Moderate ___ Severe
+58 ;;
+59 ;; 13. Other neurologic abnormalities
+60 ;;
+61 ;; Does the Veteran have any other neurologic abnormalities or findings related
+62 ;; to a thoracolumbar spine (back) condition (such as bowel or bladder
+63 ;; problems/pathologic reflexes)?
+64 ;; ___ Yes ___ No
+65 ;;
+66 ;; If yes, describe condition and how it is related: __________________________
+67 ;;
+68 ;; If there are neurological abnormalities other than radiculopathy, also
+69 ;; complete appropriate Questionnaire for each condition identified.
+70 ;;
+71 ;; 14. Intervertebral disc syndrome (IVDS) and incapacitating episodes
+72 ;;
+73 ;; a. Does the Veteran have IVDS of the thoracolumbar spine?
+74 ;; ___ Yes ___ No
+75 ;;
+76 ;; b. If yes, has the Veteran had any incapacitating episodes over the past 12
+77 ;; months due to IVDS?
+78 ;; ___ Yes ___ No
+79 ;;
+80 ;; NOTE: For VA purposes, an incapacitating episode is a period of acute
+81 ;; symptoms severe enough to require prescribed bed rest and treatment by a
+82 ;; physician.
+83 ;;
+84 ;; If yes, provide the total duration of all incapacitating episodes over the
+85 ;; past 12 months:
+86 ;; ___ Less than 1 week
+87 ;; ___ At least 1 week but less than 2 weeks
+88 ;; ___ At least 2 weeks but less than 4 weeks
+89 ;; ___ At least 4 weeks but less than 6 weeks
+90 ;; ___ At least 6 weeks
+91 ;;^TOF^
+92 ;; 15. Assistive devices
+93 ;;
+94 ;; a. Does the Veteran use any assistive device(s) as a normal mode of
+95 ;; locomotion, although occasional locomotion by other methods may be possible?
+96 ;; ___ Yes ___ No
+97 ;;
+98 ;; If yes, identify assistive device(s) used (check all that apply and
+99 ;; indicate frequency):
+100 ;; ___ Wheelchair
+101 ;; Frequency of use: ___ Occasional ___ Regular ___ Constant
+102 ;; ___ Brace(s)
+103 ;; Frequency of use: ___ Occasional ___ Regular ___ Constant
+104 ;; ___ Crutch(es)
+105 ;; Frequency of use: ___ Occasional ___ Regular ___ Constant
+106 ;; ___ Cane(s)
+107 ;; Frequency of use: ___ Occasional ___ Regular ___ Constant
+108 ;; ___ Walker
+109 ;; Frequency of use: ___ Occasional ___ Regular ___ Constant
+110 ;; ___ Other: _______________________________________________________________
+111 ;; Frequency of use: ___ Occasional ___ Regular ___ Constant
+112 ;;
+113 ;; b. If the Veteran uses any assistive devices, specify the condition and
+114 ;; identify the assistive device used for each condition: _____________________
+115 ;; ____________________________________________________________________________
+116 ;;
+117 ;; 16. Remaining effective function of the extremities
+118 ;;
+119 ;; Due to a thoracolumbar spine (back) condition, is there functional
+120 ;; impairment of an extremity such that no effective function remains other
+121 ;; than that which would be equally well served by an amputation with
+122 ;; prosthesis? (Functions of the upper extremity include grasping,
+123 ;; manipulation, etc.; functions of the lower extremity include balance and
+124 ;; propulsion, etc.)
+125 ;;
+126 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+127 ;; equally serve the Veteran.
+128 ;; ___ No
+129 ;; If yes, indicate extremity(ies) (check all extremities for which this
+130 ;; applies):
+131 ;; ___ Right lower ___ Left lower
+132 ;;^TOF^
+133 ;; 17. Other pertinent physical findings, complications, conditions, signs
+134 ;; and/or symptoms
+135 ;;
+136 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+137 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+138 ;; section above?
+139 ;; ___ Yes ___ No
+140 ;;
+141 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+142 ;; of all related scars greater than 39 square cm (6 square inches)?
+143 ;; ___ Yes ___ No
+144 ;; If yes, also complete a Scars Questionnaire.
+145 ;;
+146 ;; b. Does the Veteran have any other pertinent physical findings,
+147 ;; complications, conditions, signs or symptoms?
+148 ;; ___ Yes ___ No
+149 ;;
+150 ;; If yes, describe (brief summary)____________________________________________
+151 ;;
+152 ;; 18. Diagnostic testing
+153 ;;
+154 ;; The diagnosis of arthritis must be confirmed by imaging studies. Once
+155 ;; arthritis has been documented, no further imaging studies are required by
+156 ;; VA, even if arthritis has worsened.
+157 ;;
+158 ;; Imaging studies are not required to make the diagnosis of IVDS;
+159 ;; Electromyography (EMG) studies are rarely required to diagnose radiculopathy
+160 ;; in the appropriate clinical setting.
+161 ;;
+162 ;; For purposes of this examination, the diagnosis of IVDS and/or radiculopathy
+163 ;; can be made by a history of characteristic radiating pain and/or sensory
+164 ;; changes in the legs, and objective clinical findings, which may include the
+165 ;; asymmetrical loss or decrease of reflexes, decreased strength and/or
+166 ;; abnormal sensation.
+167 ;;
+168 ;; a. Have imaging studies of the thoracolumbar spine been performed and are
+169 ;; the results available?
+170 ;; ___ Yes ___ No
+171 ;;
+172 ;; If yes, is arthritis documented?
+173 ;; ___ Yes ___ No
+174 ;;
+175 ;; b. Does the Veteran have a vertebral fracture?
+176 ;; ___ Yes ___ No
+177 ;;
+178 ;; If yes, provide percent of loss of vertebral body: ____________
+179 ;;^TOF^
+180 ;; c. Are there any other significant diagnostic test findings and/or results?
+181 ;; ___ Yes ___ No
+182 ;;
+183 ;; If yes, provide type of test or procedure, date and results (brief summary):
+184 ;; ____________________________________________________________________________
+185 ;;
+186 ;; 19. Functional impact
+187 ;;
+188 ;; Does the Veteran's thoracolumbar spine (back) condition impact his or her
+189 ;; ability to work?
+190 ;; ___ Yes ___ No
+191 ;;
+192 ;; If yes describe the impact of each of the Veteran's thoracolumbar spine
+193 ;; (back) conditions providing one or more examples ___________________________
+194 ;;
+195 ;;_____________________________________________________________________________
+196 ;;
+197 ;; 20. Remarks, if any:
+198 ;; ____________________________________________________________________________
+199 ;;
+200 ;; Physician signature: ____________________________________ Date: ____________
+201 ;;
+202 ;; Physician printed name: ____________________________________________________
+203 ;;
+204 ;; Medical license #: _________________________________________________________
+205 ;;
+206 ;; Physician address: _________________________________________________________
+207 ;;
+208 ;; Phone: _____________________________ FAX: ______________________________
+209 ;;
+210 ;; NOTE: VA may request additional medical information, including additional
+211 ;; examinations if necessary to complete VA's review of the Veteran's
+212 ;; application.
+213 ;;
+214 ;;^END^
+215 QUIT
