DVBCQCN2 ;;ALB-CIOFO/ECF - CENTRAL NERVOUS SYSTEM QUESTIONNAIRE ; 6/20/2011
;;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.
;;
;; 1. Diagnosis
;;
;; Does the Veteran now have or has he/she ever been diagnosed with a central
;; nervous system (CNS) condition?
;; ___ Yes ___ No
;;
;; If yes, select the Veteran's condition: (check all that apply)
;; ___ CNS infections: ICD Code: ______ Date of Diagnosis: __________
;; ___ Meningitis
;; Specify organism: _______________________________________________
;; ___ Brain abscess
;; Specify organism: _______________________________________________
;; ___ HIV
;; ___ Neurosyphilis
;; ___ Lyme disease
;; ___ Encephalitis, epidemic, chronic, including poliomyelitis,
;; anterior (anterior horn cells)
;; ___ Other: specify: ________________________________________________
;; ___ Vascular diseases ICD code: ______ Date of diagnosis: __________
;; ___ Thrombosis, TIA or cerebral infarction
;; ___ Hemorrhage, specify type: _______________________________________
;; ___ Cerebral arteriosclerosis
;; ___ Other: specify: ________________________________________________
;; ___ Hydrocephalus ICD code: ______ Date of diagnosis: __________
;; ___ Obstructive
;; ___ Communicating
;; ___ Normal pressure (NPH)
;; ___ Brain tumor ICD code: ______ Date of diagnosis: __________
;; ___ Spinal Cord conditions ICD code: _____ Date of diagnosis: __________
;; ___ Syringomyelia
;; ___ Myelitis
;; ___ Hematomyelia
;; ___ Spinal Cord injuries
;; ___ Radiation injury
;; ___ Electric or lightning injury
;; ___ Decompression sickness (DCS)
;; ___ Other: specify: ____________________________________________
;; ___ Spinal cord tumor
;; ___ Other: specify: ________________________________________________
;;^TOF^
;; ___ Brain Stem Conditions ICD code: ______ Date of diagnosis: __________
;; ___ Bulbar palsy
;; ___ Pseudobulbar palsy
;; ___ Other: specify: ________________________________________________
;; ___ Movement disorders
;; ___ Athetosis, acquired
;; ___ Myoclonus l
;; ___ Paramyoclonus multiplex (convulsive state, myoclonic type)
;; ___ Tic, convulsive (Gilles de la Tourette syndrome)
;; ___ Dystonia, specify type: _________________________________________
;; ___ Essential tremor
;; ___ Tardive dyskenesia or other neuroleptic induced syndromes
;; ___ Other: specify: ________________________________________________
;; ___ Neuromuscular disorders
;; ___ Myasthenia gravis
;; ___ Myasthenic syndrome
;; ___ Botulism
;; ___ Hereditary muscular disorders specify: __________________________
;; ___ Familial periodic paralysis
;; ___ Myoglobulinuria
;; ___ Dermatomyositis or polyomiositis, specify: ______________________
;; ___ Other: specify: ________________________________________________
;; ___ Intoxications
;; ___ Heavy metal intoxication
;; Specify: _____________________________________________________
;; ___ Solvents
;; Specify: _____________________________________________________
;; ___ Insecticides, pesticides, others
;; Specify: _____________________________________________________
;; ___ Nerve gas agents
;; ___ Herbicides/defoliants
;; Specify: _____________________________________________________
;; ___ Other: specify: ________________________________________________
;;
;; ___ Other central nervous condition
;; Other diagnosis #1: ______________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; Other diagnosis #2: ______________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; If there are additional diagnoses that pertain to central nervous
;; conditions, list using above format: _______________________________________
;;^TOF^
;; 2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's
;; central nervous conditions (brief summary): ________________________________
;;_____________________________________________________________________________
;;
;; b. Does the Veteran's central nervous system condition require continuous
;; medication for control?
;; ___ Yes ___ No
;; If yes, list medications used for central nervous system conditions: _______
;; ____________________________________________________________________________
;;
;; c. Does the Veteran have an infectious condition?
;; ___ Yes ___ No
;; If yes, is it active?
;; ___ Yes ___ No
;; If no, describe residuals if any: __________________________________________
;;
;; d. Dominant hand
;; ___ Right ___ Left ___ Ambidextrous
;;
;; 3. Conditions, signs and symptoms
;;
;; a. Does the Veteran have any muscle weakness in the upper and/or lower
;; extremities?
;; ___ Yes ___ No
;; If yes, report under strength testing in neurologic exam section.
;;
;; b. Does the Veteran have any pharynx and/or larynx and/or swallowing
;; conditions?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Constant inability to communicate by speech
;; ___ Speech not intelligible or individual is aphonic
;; ___ Paralysis of soft palate with swallowing difficulty (nasal
;; regurgitation) and speech impairment
;; ___ Hoarseness
;; ___ Mild swallowing difficulties
;; ___ Moderate swallowing difficulties
;; ___ Severe swallowing difficulties, permitting passage of liquids only
;; ___ Requires feeding tube due to swallowing difficulties
;; ___ Other, describe: ____________________________________________________
;;
;; c. Does the Veteran have any respiratory conditions (such as rigidity of the
;; diaphragm, chest wall or laryngeal muscles)?
;; ___ Yes ___ No
;; If yes, provide PFT results under "Diagnostic testing" section.
;;^TOF^
;; d. Does the Veteran have sleep disturbances?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Insomnia
;; ___ Hypersomnolence and/or daytime "sleep attacks"
;; ___ Persistent daytime hypersomnolence
;; ___ Sleep apnea requiring the use of breathing assistance device such
;; as continuous positive airway pressure (CPAP) machine
;; ___ Sleep apnea causing chronic respiratory failure with carbon dioxide
;; retention or cor pulmonale
;; ___ Sleep apnea requiring tracheostomy
;;
;; e. Does the Veteran have any bowel functional impairment?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Slight impairment of sphincter control, without leakage
;; ___ Constant slight impairment of sphincter control, or occasional
;; moderate leakage
;; ___ Occasional involuntary bowel movements, necessitating wearing of
;; a pad
;; ___ Extensive leakage and fairly frequent involuntary bowel movements
;; ___ Total loss of bowel sphincter control
;; ___ Chronic constipation
;; ___ Other bowel impairment (describe): __________________________________
;;
;; f. Does the Veteran have voiding dysfunction causing urine leakage?
;; ___ Yes ___ No
;; If yes, please check one:
;; ___ Does not require/does not use absorbent material
;; ___ Requires absorbent material that is changed less than 2 times per day
;; ___ Requires absorbent material that is changed 2 to 4 times per day
;; ___ Requires absorbent material that is changed more than 4 times per day
;;
;; g. Does the Veteran have voiding dysfunction causing signs and/or symptoms
;; of urinary frequency?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Daytime voiding interval between 2 and 3 hours
;; ___ Daytime voiding interval between 1 and 2 hours
;; ___ Daytime voiding interval less than 1 hour
;; ___ Nighttime awakening to void 2 times
;; ___ Nighttime awakening to void 3 to 4 times
;; ___ Nighttime awakening to void 5 or more times
;;^TOF^
;; h. Does the Veteran have voiding dysfunction causing findings, signs and/or
;; symptoms of obstructed voiding?
;; ___ Yes ___ No
;; If yes, check all signs and symptoms that apply:
;; ___ Hesitancy
;; If checked, is hesitancy marked?
;; ___ Yes ___ No
;; ___ Slow or weak stream
;; If checked, is stream markedly slow or weak?
;; ___ Yes ___ No
;; ___ Decreased force of stream
;; If checked, is force of stream markedly decreased?
;; ___ Yes ___ No
;; ___ Stricture disease requiring dilatation 1 to 2 times per year
;; ___ Stricture disease requiring periodic dilatation every 2 to 3 months
;; ___ Recurrent urinary tract infections secondary to obstruction
;; ___ Uroflowmetry peak flow rate less than 10 cc/sec
;; ___ Post void residuals greater than 150 cc
;; ___ Urinary retention requiring intermittent or continuous
;; catheterization
;;
;; i. Does the Veteran have voiding dysfunction requiring the use of an
;; appliance?
;; ___ Yes ___ No
;; If yes, describe: __________________________________________________________
;;
;; j. Does the Veteran have a history of recurrent symptomatic urinary tract
;; infections?
;; ___ Yes ___ No
;; If yes, check all treatments that apply:
;; ___ No treatment
;; ___ Long-term drug therapy
;; If checked, list medications used for urinary tract infection and
;; indicate dates for courses of treatment over the past 12 months:
;; _____________________________________________________________________
;; ___ Hospitalization
;; If checked, indicate frequency of hospitalization:
;; ___ 1 or 2 per year
;; ___ More than 2 per year
;; ___ Drainage
;; If checked, indicate dates when drainage performed over past 12
;; months: _____________________________________________________________
;; ___ Other management/treatment not listed above
;; Description of management/treatment including dates of treatment:
;; _____________________________________________________________________
;;^TOF^
;; k. Does the Veteran (if male) have erectile dysfunction?
;; ___ Yes ___ No
;; If yes, is the erectile dysfunction as likely as not (at least a 50%
;; probability) attributable to a CNS disease (including treatment or residuals
;; of treatment)?
;; ___ Yes ___ No
;; If no, provide the etiology of the erectile dysfunction: ____________
;; _____________________________________________________________________
;; If yes, is the Veteran able to achieve an erection (without
;; medication) sufficient for penetration and ejaculation?
;; ___ Yes ___ No
;; If no, is the Veteran able to achieve an erection (with
;; medication) sufficient for penetration and ejaculation?
;; ___ Yes ___ No
;;
;; 4. Neurologic exam
;;
;; a. Speech
;; ___ Normal ___ Abnormal
;; If speech is abnormal, describe: ___________________________________________
;;
;; b. Gait
;; ___ Normal ___ Abnormal, describe: ______________________________________
;; If gait is abnormal, and the Veteran has more than one medical condition
;; contributing to the abnormal gait, identify the conditions and describe each
;; condition's contribution to the abnormal gait: _____________________________
;;
;; c. Strength
;; Rate strength according to the following scale:
;; 0/5 No muscle movement
;; 1/5 Visible muscle movement, but no joint movement
;; 2/5 No movement against gravity
;; 3/5 No movement against resistance
;; 4/5 Less than normal strength
;; 5/5 Normal strength
;;
;; ___ All normal
;; Elbow 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
;; Elbow 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
;; Wrist 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
;; Wrist 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
;;^TOF^
;; Grip: 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
;; Pinch (thumb to index finger):
;; 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
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQCN2 14327 printed Dec 13, 2024@01:45:54 Page 2
DVBCQCN2 ;;ALB-CIOFO/ECF - CENTRAL NERVOUS SYSTEM QUESTIONNAIRE ; 6/20/2011
+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 Veteran's
+5 ;; claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran now have or has he/she ever been diagnosed with a central
+10 ;; nervous system (CNS) condition?
+11 ;; ___ Yes ___ No
+12 ;;
+13 ;; If yes, select the Veteran's condition: (check all that apply)
+14 ;; ___ CNS infections: ICD Code: ______ Date of Diagnosis: __________
+15 ;; ___ Meningitis
+16 ;; Specify organism: _______________________________________________
+17 ;; ___ Brain abscess
+18 ;; Specify organism: _______________________________________________
+19 ;; ___ HIV
+20 ;; ___ Neurosyphilis
+21 ;; ___ Lyme disease
+22 ;; ___ Encephalitis, epidemic, chronic, including poliomyelitis,
+23 ;; anterior (anterior horn cells)
+24 ;; ___ Other: specify: ________________________________________________
+25 ;; ___ Vascular diseases ICD code: ______ Date of diagnosis: __________
+26 ;; ___ Thrombosis, TIA or cerebral infarction
+27 ;; ___ Hemorrhage, specify type: _______________________________________
+28 ;; ___ Cerebral arteriosclerosis
+29 ;; ___ Other: specify: ________________________________________________
+30 ;; ___ Hydrocephalus ICD code: ______ Date of diagnosis: __________
+31 ;; ___ Obstructive
+32 ;; ___ Communicating
+33 ;; ___ Normal pressure (NPH)
+34 ;; ___ Brain tumor ICD code: ______ Date of diagnosis: __________
+35 ;; ___ Spinal Cord conditions ICD code: _____ Date of diagnosis: __________
+36 ;; ___ Syringomyelia
+37 ;; ___ Myelitis
+38 ;; ___ Hematomyelia
+39 ;; ___ Spinal Cord injuries
+40 ;; ___ Radiation injury
+41 ;; ___ Electric or lightning injury
+42 ;; ___ Decompression sickness (DCS)
+43 ;; ___ Other: specify: ____________________________________________
+44 ;; ___ Spinal cord tumor
+45 ;; ___ Other: specify: ________________________________________________
+46 ;;^TOF^
+47 ;; ___ Brain Stem Conditions ICD code: ______ Date of diagnosis: __________
+48 ;; ___ Bulbar palsy
+49 ;; ___ Pseudobulbar palsy
+50 ;; ___ Other: specify: ________________________________________________
+51 ;; ___ Movement disorders
+52 ;; ___ Athetosis, acquired
+53 ;; ___ Myoclonus l
+54 ;; ___ Paramyoclonus multiplex (convulsive state, myoclonic type)
+55 ;; ___ Tic, convulsive (Gilles de la Tourette syndrome)
+56 ;; ___ Dystonia, specify type: _________________________________________
+57 ;; ___ Essential tremor
+58 ;; ___ Tardive dyskenesia or other neuroleptic induced syndromes
+59 ;; ___ Other: specify: ________________________________________________
+60 ;; ___ Neuromuscular disorders
+61 ;; ___ Myasthenia gravis
+62 ;; ___ Myasthenic syndrome
+63 ;; ___ Botulism
+64 ;; ___ Hereditary muscular disorders specify: __________________________
+65 ;; ___ Familial periodic paralysis
+66 ;; ___ Myoglobulinuria
+67 ;; ___ Dermatomyositis or polyomiositis, specify: ______________________
+68 ;; ___ Other: specify: ________________________________________________
+69 ;; ___ Intoxications
+70 ;; ___ Heavy metal intoxication
+71 ;; Specify: _____________________________________________________
+72 ;; ___ Solvents
+73 ;; Specify: _____________________________________________________
+74 ;; ___ Insecticides, pesticides, others
+75 ;; Specify: _____________________________________________________
+76 ;; ___ Nerve gas agents
+77 ;; ___ Herbicides/defoliants
+78 ;; Specify: _____________________________________________________
+79 ;; ___ Other: specify: ________________________________________________
+80 ;;
+81 ;; ___ Other central nervous condition
+82 ;; Other diagnosis #1: ______________
+83 ;; ICD code: ________________________
+84 ;; Date of diagnosis: _______________
+85 ;;
+86 ;; Other diagnosis #2: ______________
+87 ;; ICD code: ________________________
+88 ;; Date of diagnosis: _______________
+89 ;;
+90 ;; If there are additional diagnoses that pertain to central nervous
+91 ;; conditions, list using above format: _______________________________________
+92 ;;^TOF^
+93 ;; 2. Medical history
+94 ;;
+95 ;; a. Describe the history (including onset and course) of the Veteran's
+96 ;; central nervous conditions (brief summary): ________________________________
+97 ;;_____________________________________________________________________________
+98 ;;
+99 ;; b. Does the Veteran's central nervous system condition require continuous
+100 ;; medication for control?
+101 ;; ___ Yes ___ No
+102 ;; If yes, list medications used for central nervous system conditions: _______
+103 ;; ____________________________________________________________________________
+104 ;;
+105 ;; c. Does the Veteran have an infectious condition?
+106 ;; ___ Yes ___ No
+107 ;; If yes, is it active?
+108 ;; ___ Yes ___ No
+109 ;; If no, describe residuals if any: __________________________________________
+110 ;;
+111 ;; d. Dominant hand
+112 ;; ___ Right ___ Left ___ Ambidextrous
+113 ;;
+114 ;; 3. Conditions, signs and symptoms
+115 ;;
+116 ;; a. Does the Veteran have any muscle weakness in the upper and/or lower
+117 ;; extremities?
+118 ;; ___ Yes ___ No
+119 ;; If yes, report under strength testing in neurologic exam section.
+120 ;;
+121 ;; b. Does the Veteran have any pharynx and/or larynx and/or swallowing
+122 ;; conditions?
+123 ;; ___ Yes ___ No
+124 ;; If yes, check all that apply:
+125 ;; ___ Constant inability to communicate by speech
+126 ;; ___ Speech not intelligible or individual is aphonic
+127 ;; ___ Paralysis of soft palate with swallowing difficulty (nasal
+128 ;; regurgitation) and speech impairment
+129 ;; ___ Hoarseness
+130 ;; ___ Mild swallowing difficulties
+131 ;; ___ Moderate swallowing difficulties
+132 ;; ___ Severe swallowing difficulties, permitting passage of liquids only
+133 ;; ___ Requires feeding tube due to swallowing difficulties
+134 ;; ___ Other, describe: ____________________________________________________
+135 ;;
+136 ;; c. Does the Veteran have any respiratory conditions (such as rigidity of the
+137 ;; diaphragm, chest wall or laryngeal muscles)?
+138 ;; ___ Yes ___ No
+139 ;; If yes, provide PFT results under "Diagnostic testing" section.
+140 ;;^TOF^
+141 ;; d. Does the Veteran have sleep disturbances?
+142 ;; ___ Yes ___ No
+143 ;; If yes, check all that apply:
+144 ;; ___ Insomnia
+145 ;; ___ Hypersomnolence and/or daytime "sleep attacks"
+146 ;; ___ Persistent daytime hypersomnolence
+147 ;; ___ Sleep apnea requiring the use of breathing assistance device such
+148 ;; as continuous positive airway pressure (CPAP) machine
+149 ;; ___ Sleep apnea causing chronic respiratory failure with carbon dioxide
+150 ;; retention or cor pulmonale
+151 ;; ___ Sleep apnea requiring tracheostomy
+152 ;;
+153 ;; e. Does the Veteran have any bowel functional impairment?
+154 ;; ___ Yes ___ No
+155 ;; If yes, check all that apply:
+156 ;; ___ Slight impairment of sphincter control, without leakage
+157 ;; ___ Constant slight impairment of sphincter control, or occasional
+158 ;; moderate leakage
+159 ;; ___ Occasional involuntary bowel movements, necessitating wearing of
+160 ;; a pad
+161 ;; ___ Extensive leakage and fairly frequent involuntary bowel movements
+162 ;; ___ Total loss of bowel sphincter control
+163 ;; ___ Chronic constipation
+164 ;; ___ Other bowel impairment (describe): __________________________________
+165 ;;
+166 ;; f. Does the Veteran have voiding dysfunction causing urine leakage?
+167 ;; ___ Yes ___ No
+168 ;; If yes, please check one:
+169 ;; ___ Does not require/does not use absorbent material
+170 ;; ___ Requires absorbent material that is changed less than 2 times per day
+171 ;; ___ Requires absorbent material that is changed 2 to 4 times per day
+172 ;; ___ Requires absorbent material that is changed more than 4 times per day
+173 ;;
+174 ;; g. Does the Veteran have voiding dysfunction causing signs and/or symptoms
+175 ;; of urinary frequency?
+176 ;; ___ Yes ___ No
+177 ;; If yes, check all that apply:
+178 ;; ___ Daytime voiding interval between 2 and 3 hours
+179 ;; ___ Daytime voiding interval between 1 and 2 hours
+180 ;; ___ Daytime voiding interval less than 1 hour
+181 ;; ___ Nighttime awakening to void 2 times
+182 ;; ___ Nighttime awakening to void 3 to 4 times
+183 ;; ___ Nighttime awakening to void 5 or more times
+184 ;;^TOF^
+185 ;; h. Does the Veteran have voiding dysfunction causing findings, signs and/or
+186 ;; symptoms of obstructed voiding?
+187 ;; ___ Yes ___ No
+188 ;; If yes, check all signs and symptoms that apply:
+189 ;; ___ Hesitancy
+190 ;; If checked, is hesitancy marked?
+191 ;; ___ Yes ___ No
+192 ;; ___ Slow or weak stream
+193 ;; If checked, is stream markedly slow or weak?
+194 ;; ___ Yes ___ No
+195 ;; ___ Decreased force of stream
+196 ;; If checked, is force of stream markedly decreased?
+197 ;; ___ Yes ___ No
+198 ;; ___ Stricture disease requiring dilatation 1 to 2 times per year
+199 ;; ___ Stricture disease requiring periodic dilatation every 2 to 3 months
+200 ;; ___ Recurrent urinary tract infections secondary to obstruction
+201 ;; ___ Uroflowmetry peak flow rate less than 10 cc/sec
+202 ;; ___ Post void residuals greater than 150 cc
+203 ;; ___ Urinary retention requiring intermittent or continuous
+204 ;; catheterization
+205 ;;
+206 ;; i. Does the Veteran have voiding dysfunction requiring the use of an
+207 ;; appliance?
+208 ;; ___ Yes ___ No
+209 ;; If yes, describe: __________________________________________________________
+210 ;;
+211 ;; j. Does the Veteran have a history of recurrent symptomatic urinary tract
+212 ;; infections?
+213 ;; ___ Yes ___ No
+214 ;; If yes, check all treatments that apply:
+215 ;; ___ No treatment
+216 ;; ___ Long-term drug therapy
+217 ;; If checked, list medications used for urinary tract infection and
+218 ;; indicate dates for courses of treatment over the past 12 months:
+219 ;; _____________________________________________________________________
+220 ;; ___ Hospitalization
+221 ;; If checked, indicate frequency of hospitalization:
+222 ;; ___ 1 or 2 per year
+223 ;; ___ More than 2 per year
+224 ;; ___ Drainage
+225 ;; If checked, indicate dates when drainage performed over past 12
+226 ;; months: _____________________________________________________________
+227 ;; ___ Other management/treatment not listed above
+228 ;; Description of management/treatment including dates of treatment:
+229 ;; _____________________________________________________________________
+230 ;;^TOF^
+231 ;; k. Does the Veteran (if male) have erectile dysfunction?
+232 ;; ___ Yes ___ No
+233 ;; If yes, is the erectile dysfunction as likely as not (at least a 50%
+234 ;; probability) attributable to a CNS disease (including treatment or residuals
+235 ;; of treatment)?
+236 ;; ___ Yes ___ No
+237 ;; If no, provide the etiology of the erectile dysfunction: ____________
+238 ;; _____________________________________________________________________
+239 ;; If yes, is the Veteran able to achieve an erection (without
+240 ;; medication) sufficient for penetration and ejaculation?
+241 ;; ___ Yes ___ No
+242 ;; If no, is the Veteran able to achieve an erection (with
+243 ;; medication) sufficient for penetration and ejaculation?
+244 ;; ___ Yes ___ No
+245 ;;
+246 ;; 4. Neurologic exam
+247 ;;
+248 ;; a. Speech
+249 ;; ___ Normal ___ Abnormal
+250 ;; If speech is abnormal, describe: ___________________________________________
+251 ;;
+252 ;; b. Gait
+253 ;; ___ Normal ___ Abnormal, describe: ______________________________________
+254 ;; If gait is abnormal, and the Veteran has more than one medical condition
+255 ;; contributing to the abnormal gait, identify the conditions and describe each
+256 ;; condition's contribution to the abnormal gait: _____________________________
+257 ;;
+258 ;; c. Strength
+259 ;; Rate strength according to the following scale:
+260 ;; 0/5 No muscle movement
+261 ;; 1/5 Visible muscle movement, but no joint movement
+262 ;; 2/5 No movement against gravity
+263 ;; 3/5 No movement against resistance
+264 ;; 4/5 Less than normal strength
+265 ;; 5/5 Normal strength
+266 ;;
+267 ;; ___ All normal
+268 ;; Elbow flexion:
+269 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+270 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+271 ;; Elbow extension:
+272 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+273 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+274 ;; Wrist flexion:
+275 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+276 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+277 ;; Wrist extension:
+278 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+279 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+280 ;;^TOF^
+281 ;; Grip: Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+282 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+283 ;; Pinch (thumb to index finger):
+284 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+285 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+286 ;; Knee extension:
+287 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+288 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+289 ;; Ankle plantar flexion:
+290 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+291 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+292 ;; Ankle dorsiflexion:
+293 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+294 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+295 ;;
+296 QUIT
