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Routine: DVBCQCN2

DVBCQCN2.m

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  1. DVBCQCN2 ;;ALB-CIOFO/ECF - CENTRAL NERVOUS SYSTEM QUESTIONNAIRE ; 6/20/2011
  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 Veteran's
  1.  ;; claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;;
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with a central
  1.  ;; nervous system (CNS) condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, select the Veteran's condition: (check all that apply)
  1.  ;;    ___ CNS infections:       ICD Code: ______  Date of Diagnosis: __________
  1.  ;;        ___ Meningitis
  1.  ;;            Specify organism: _______________________________________________
  1.  ;;        ___ Brain abscess
  1.  ;;            Specify organism: _______________________________________________
  1.  ;;        ___ HIV
  1.  ;;        ___ Neurosyphilis
  1.  ;;        ___ Lyme disease
  1.  ;;        ___ Encephalitis, epidemic, chronic, including poliomyelitis,
  1.  ;;            anterior (anterior horn cells)
  1.  ;;        ___ Other:  specify: ________________________________________________
  1.  ;;    ___ Vascular diseases     ICD code: ______  Date of diagnosis: __________
  1.  ;;        ___ Thrombosis, TIA or cerebral infarction
  1.  ;;        ___ Hemorrhage, specify type: _______________________________________
  1.  ;;        ___ Cerebral arteriosclerosis
  1.  ;;        ___ Other:  specify: ________________________________________________
  1.  ;;    ___ Hydrocephalus         ICD code: ______  Date of diagnosis: __________
  1.  ;;        ___ Obstructive
  1.  ;;        ___ Communicating
  1.  ;;        ___ Normal pressure (NPH)
  1.  ;;    ___ Brain tumor           ICD code: ______  Date of diagnosis: __________
  1.  ;;    ___ Spinal Cord conditions  ICD code: _____ Date of diagnosis: __________
  1.  ;;        ___ Syringomyelia
  1.  ;;        ___ Myelitis
  1.  ;;        ___ Hematomyelia
  1.  ;;        ___ Spinal Cord injuries
  1.  ;;            ___ Radiation injury
  1.  ;;            ___ Electric or lightning injury
  1.  ;;            ___ Decompression sickness (DCS)
  1.  ;;            ___ Other:  specify: ____________________________________________
  1.  ;;        ___ Spinal cord tumor
  1.  ;;        ___ Other:  specify: ________________________________________________
  1.  ;;^TOF^
  1.  ;;    ___ Brain Stem Conditions ICD code: ______  Date of diagnosis: __________
  1.  ;;        ___ Bulbar palsy
  1.  ;;        ___ Pseudobulbar palsy
  1.  ;;        ___ Other:  specify: ________________________________________________
  1.  ;;    ___ Movement disorders
  1.  ;;        ___ Athetosis, acquired
  1.  ;;        ___ Myoclonus l
  1.  ;;        ___ Paramyoclonus multiplex (convulsive state, myoclonic type)
  1.  ;;        ___ Tic, convulsive (Gilles de la Tourette syndrome)
  1.  ;;        ___ Dystonia, specify type: _________________________________________
  1.  ;;        ___ Essential tremor
  1.  ;;        ___ Tardive dyskenesia or other neuroleptic induced syndromes
  1.  ;;        ___ Other:  specify: ________________________________________________
  1.  ;;    ___ Neuromuscular disorders
  1.  ;;        ___ Myasthenia gravis
  1.  ;;        ___ Myasthenic syndrome
  1.  ;;        ___ Botulism
  1.  ;;        ___ Hereditary muscular disorders specify: __________________________
  1.  ;;        ___ Familial periodic paralysis
  1.  ;;        ___ Myoglobulinuria
  1.  ;;        ___ Dermatomyositis or polyomiositis, specify: ______________________
  1.  ;;        ___ Other:  specify: ________________________________________________
  1.  ;;    ___ Intoxications
  1.  ;;        ___ Heavy metal intoxication
  1.  ;;               Specify: _____________________________________________________
  1.  ;;        ___ Solvents
  1.  ;;               Specify: _____________________________________________________
  1.  ;;        ___ Insecticides, pesticides, others
  1.  ;;               Specify: _____________________________________________________
  1.  ;;        ___ Nerve gas agents
  1.  ;;        ___ Herbicides/defoliants
  1.  ;;               Specify: _____________________________________________________
  1.  ;;        ___ Other:  specify: ________________________________________________
  1.  ;;
  1.  ;; ___ Other central nervous condition
  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.  ;; If there are additional diagnoses that pertain to central nervous
  1.  ;; conditions, list using above format: _______________________________________
  1.  ;;^TOF^
  1.  ;; 2. Medical history
  1.  ;;
  1.  ;; a. Describe the history (including onset and course) of the Veteran's
  1.  ;; central nervous conditions (brief summary): ________________________________
  1.  ;;_____________________________________________________________________________
  1.  ;;
  1.  ;; b. Does the Veteran's central nervous system condition require continuous
  1.  ;; medication for control?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, list medications used for central nervous system conditions: _______
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; c. Does the Veteran have an infectious condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, is it active?
  1.  ;; ___ Yes   ___ No
  1.  ;; If no, describe residuals if any: __________________________________________
  1.  ;;
  1.  ;; d. Dominant hand
  1.  ;; ___ Right    ___ Left    ___ Ambidextrous
  1.  ;;
  1.  ;; 3. Conditions, signs and symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have any muscle weakness in the upper and/or lower
  1.  ;; extremities?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, report under strength testing in neurologic exam section.
  1.  ;;
  1.  ;; b. Does the Veteran have any pharynx and/or larynx and/or swallowing
  1.  ;; conditions?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Constant inability to communicate by speech
  1.  ;;    ___ Speech not intelligible or individual is aphonic
  1.  ;;    ___ Paralysis of soft palate with swallowing difficulty (nasal
  1.  ;;        regurgitation) and speech impairment
  1.  ;;    ___ Hoarseness
  1.  ;;    ___ Mild swallowing difficulties
  1.  ;;    ___ Moderate swallowing difficulties
  1.  ;;    ___ Severe swallowing difficulties, permitting passage of liquids only
  1.  ;;    ___ Requires feeding tube due to swallowing difficulties
  1.  ;;    ___ Other, describe: ____________________________________________________
  1.  ;;
  1.  ;; c. Does the Veteran have any respiratory conditions (such as rigidity of the
  1.  ;; diaphragm, chest wall or laryngeal muscles)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide PFT results under "Diagnostic testing" section.
  1.  ;;^TOF^
  1.  ;; d. Does the Veteran have sleep disturbances?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Insomnia
  1.  ;;        ___ Hypersomnolence and/or daytime "sleep attacks"
  1.  ;;        ___ Persistent daytime hypersomnolence
  1.  ;;        ___ Sleep apnea requiring the use of breathing assistance device such
  1.  ;;            as continuous positive airway pressure (CPAP) machine
  1.  ;;    ___ Sleep apnea causing chronic respiratory failure with carbon dioxide
  1.  ;;        retention or cor pulmonale
  1.  ;;    ___ Sleep apnea requiring tracheostomy
  1.  ;;
  1.  ;; e. Does the Veteran have any bowel functional impairment?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Slight impairment of sphincter control, without leakage
  1.  ;;    ___ Constant slight impairment of sphincter control, or occasional
  1.  ;;        moderate leakage
  1.  ;;    ___ Occasional involuntary bowel movements, necessitating wearing of
  1.  ;;        a pad
  1.  ;;    ___ Extensive leakage and fairly frequent involuntary bowel movements
  1.  ;;    ___ Total loss of bowel sphincter control
  1.  ;;    ___ Chronic constipation
  1.  ;;    ___ Other bowel impairment (describe): __________________________________
  1.  ;;
  1.  ;; f. Does the Veteran have voiding dysfunction causing urine leakage?
  1.  ;; ___ Yes  ___ No
  1.  ;; If yes, please check one:
  1.  ;;    ___ Does not require/does not use absorbent material
  1.  ;;    ___ Requires absorbent material that is changed less than 2 times per day
  1.  ;;    ___ Requires absorbent material that is changed 2 to 4 times per day
  1.  ;;    ___ Requires absorbent material that is changed more than 4 times per day
  1.  ;;
  1.  ;; g. Does the Veteran have voiding dysfunction causing signs and/or symptoms
  1.  ;; of urinary frequency?
  1.  ;; ___ Yes  ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Daytime voiding interval between 2 and 3 hours
  1.  ;;    ___ Daytime voiding interval between 1 and 2 hours
  1.  ;;    ___ Daytime voiding interval less than 1 hour
  1.  ;;    ___ Nighttime awakening to void 2 times
  1.  ;;    ___ Nighttime awakening to void 3 to 4 times
  1.  ;;    ___ Nighttime awakening to void 5 or more times
  1.  ;;^TOF^
  1.  ;; h. Does the Veteran have voiding dysfunction causing findings, signs and/or
  1.  ;; symptoms of obstructed voiding?
  1.  ;; ___ Yes  ___ No
  1.  ;; If yes, check all signs and symptoms that apply:
  1.  ;;    ___ Hesitancy
  1.  ;;        If checked, is hesitancy marked?
  1.  ;;        ___ Yes   ___ No
  1.  ;;    ___ Slow or weak stream
  1.  ;;        If checked, is stream markedly slow or weak?
  1.  ;;        ___ Yes   ___ No
  1.  ;;    ___ Decreased force of stream
  1.  ;;        If checked, is force of stream markedly decreased?
  1.  ;;        ___ Yes   ___ No
  1.  ;;    ___ Stricture disease requiring dilatation 1 to 2 times per year
  1.  ;;    ___ Stricture disease requiring periodic dilatation every 2 to 3 months
  1.  ;;    ___ Recurrent urinary tract infections secondary to obstruction
  1.  ;;    ___ Uroflowmetry peak flow rate less than 10 cc/sec
  1.  ;;    ___ Post void residuals greater than 150 cc
  1.  ;;    ___ Urinary retention requiring intermittent or continuous
  1.  ;;        catheterization
  1.  ;;
  1.  ;; i. Does the Veteran have voiding dysfunction requiring the use of an
  1.  ;; appliance?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe: __________________________________________________________
  1.  ;;
  1.  ;; j. Does the Veteran have a history of recurrent symptomatic urinary tract
  1.  ;; infections?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all treatments that apply:
  1.  ;;    ___ No treatment
  1.  ;;    ___ Long-term drug therapy
  1.  ;;        If checked, list medications used for urinary tract infection and
  1.  ;;        indicate dates for courses of treatment over the past 12 months:
  1.  ;;        _____________________________________________________________________
  1.  ;;        ___ Hospitalization
  1.  ;;            If checked, indicate frequency of hospitalization:
  1.  ;;            ___ 1 or 2 per year
  1.  ;;            ___  More than 2 per year
  1.  ;;    ___ Drainage
  1.  ;;        If checked, indicate dates when drainage performed over past 12
  1.  ;;        months: _____________________________________________________________
  1.  ;;    ___ Other management/treatment not listed above
  1.  ;;        Description of management/treatment including dates of treatment:
  1.  ;;        _____________________________________________________________________
  1.  ;;^TOF^
  1.  ;; k. Does the Veteran (if male) have erectile dysfunction?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, is the erectile dysfunction as likely as not (at least a 50%
  1.  ;; probability) attributable to a CNS disease (including treatment or residuals
  1.  ;; of treatment)?
  1.  ;;    ___ Yes   ___ No
  1.  ;;        If no, provide the etiology of the erectile dysfunction: ____________
  1.  ;;        _____________________________________________________________________
  1.  ;;        If yes, is the Veteran able to achieve an erection (without
  1.  ;;        medication) sufficient for penetration and ejaculation?
  1.  ;;        ___ Yes   ___ No
  1.  ;;            If no, is the Veteran able to achieve an erection (with
  1.  ;;            medication) sufficient for penetration and ejaculation?
  1.  ;;            ___ Yes   ___ No
  1.  ;;
  1.  ;; 4. Neurologic exam
  1.  ;;
  1.  ;; a. Speech
  1.  ;; ___ Normal   ___ Abnormal
  1.  ;; If speech is abnormal, describe: ___________________________________________
  1.  ;;
  1.  ;; b. Gait
  1.  ;; ___  Normal   ___ Abnormal, describe: ______________________________________
  1.  ;; If gait is abnormal, and the Veteran has more than one medical condition
  1.  ;; contributing to the abnormal gait, identify the conditions and describe each
  1.  ;; condition's contribution to the abnormal gait: _____________________________
  1.  ;;
  1.  ;; c. Strength
  1.  ;; Rate strength according to the following scale:
  1.  ;;    0/5 No muscle movement
  1.  ;;    1/5 Visible muscle movement, but no joint movement
  1.  ;;    2/5 No movement against gravity
  1.  ;;    3/5 No movement against resistance
  1.  ;;    4/5 Less than normal strength
  1.  ;;    5/5 Normal strength
  1.  ;;
  1.  ;; ___ All normal
  1.  ;; Elbow flexion:
  1.  ;;        Right:   ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;        Left:    ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Elbow extension:
  1.  ;;        Right:   ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;        Left:    ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Wrist flexion:
  1.  ;;        Right:   ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;        Left:    ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Wrist extension:
  1.  ;;        Right:   ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;        Left:    ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;^TOF^ 
  1.  ;; Grip:  Right:   ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;        Left:    ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Pinch (thumb to index finger):
  1.  ;;        Right:   ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;        Left:    ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Knee extension:
  1.  ;;        Right:   ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;        Left:    ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Ankle plantar flexion:
  1.  ;;        Right:   ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;        Left:    ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Ankle dorsiflexion:
  1.  ;;        Right:   ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;        Left:    ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;
  1.  Q