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Routine: DVBCQCN3

DVBCQCN3.m

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  1. DVBCQCN3 ;;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.  ;; d. Deep tendon reflexes (DTRs)
  1.  ;; Rate reflexes according to the following scale:
  1.  ;;    0  Absent
  1.  ;;    1+ Decreased
  1.  ;;    2+ Normal
  1.  ;;    3+ Increased without clonus
  1.  ;;    4+ Increased with clonus
  1.  ;;
  1.  ;; ___ All normal
  1.  ;; Biceps:            Right:   ___ 0     ___ 1+   ___ 2+   ___ 3+   ___ 4+
  1.  ;;                    Left:    ___ 0     ___ 1+   ___ 2+   ___ 3+   ___ 4+
  1.  ;; Triceps:           Right:   ___ 0     ___ 1+   ___ 2+   ___ 3+   ___ 4+
  1.  ;;                    Left:    ___ 0     ___ 1+   ___ 2+   ___ 3+   ___ 4+
  1.  ;; Brachioradialis:   Right:   ___ 0     ___ 1+   ___ 2+   ___ 3+   ___ 4+
  1.  ;;                    Left:    ___ 0     ___ 1+   ___ 2+   ___ 3+   ___ 4+
  1.  ;; Knee:              Right:   ___ 0     ___ 1+   ___ 2+   ___ 3+   ___ 4+
  1.  ;;                    Left:    ___ 0     ___ 1+   ___ 2+   ___ 3+   ___ 4+
  1.  ;; Ankle:             Right:   ___ 0     ___ 1+   ___ 2+   ___ 3+   ___ 4+
  1.  ;;                    Left:    ___ 0     ___ 1+   ___ 2+   ___ 3+   ___ 4+
  1.  ;;
  1.  ;; e. Does the Veteran have muscle atrophy attributable to a CNS condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If muscle atrophy is present, indicate location: ___________________________
  1.  ;; When possible, provide difference measured in cm between normal and
  1.  ;; atrophied side, measured at maximum muscle bulk: _____ cm.
  1.  ;;^TOF^
  1.  ;; f. Summary of muscle weakness in the upper and/or lower extremities
  1.  ;; attributable to a CNS condition (check all that apply):
  1.  ;; Right upper extremity muscle weakness:
  1.  ;;    ___ None  ___ Mild  ___ Moderate  ___ Severe  ___ With atrophy
  1.  ;;    ___ Complete (no remaining function)
  1.  ;; Left upper extremity muscle weakness:
  1.  ;;    ___ None  ___ Mild  ___ Moderate  ___ Severe  ___ With atrophy
  1.  ;;    ___ Complete (no remaining function)
  1.  ;; Right lower extremity muscle weakness:
  1.  ;;    ___ None  ___ Mild  ___ Moderate  ___ Severe  ___ With atrophy
  1.  ;;    ___ Complete (no remaining function)
  1.  ;; Left lower extremity muscle weakness:
  1.  ;;    ___ None  ___ Mild  ___ Moderate  ___ Severe  ___ With atrophy
  1.  ;;    ___ Complete (no remaining function)
  1.  ;; NOTE: If the Veteran has more than one medical condition contributing to the
  1.  ;; muscle weakness, identify the condition(s) and describe each condition's
  1.  ;; contribution to the muscle weakness: _______________________________________
  1.  ;;
  1.  ;; 5. Tumors and neoplasms
  1.  ;;
  1.  ;; a. Does the Veteran have a benign or malignant neoplasm or metastases
  1.  ;; related to any of the diagnoses in the Diagnosis section?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete the following:
  1.  ;;
  1.  ;; b. Is the neoplasm:
  1.  ;; ___ Benign  ___ Malignant
  1.  ;;
  1.  ;; c. Has the Veteran completed treatment or is the Veteran currently
  1.  ;; undergoing treatment for a benign or malignant neoplasm or metastases?
  1.  ;; ___ Yes   ___ No; watchful waiting
  1.  ;;    If yes, indicate type of treatment the Veteran is currently undergoing
  1.  ;;    or has completed (check all that apply):
  1.  ;;    ___ Treatment completed; currently in watchful waiting status
  1.  ;;    ___ Surgery
  1.  ;;        If checked, describe: _______________________________________________
  1.  ;;        Date(s) of surgery: _________________________________________________
  1.  ;;    ___ Radiation therapy   
  1.  ;;        Date of most recent treatment: ______________________________________
  1.  ;;        Date of completion of treatment or anticipated date of completion:
  1.  ;;        _____________________________________________________________________
  1.  ;;    ___ Antineoplastic chemotherapy
  1.  ;;        Date of most recent treatment: ______________________________________
  1.  ;;        Date of completion of treatment or anticipated date of completion:
  1.  ;;        _____________________________________________________________________
  1.  ;;    ___ Other therapeutic procedure
  1.  ;;        If checked, describe procedure: _____________________________________
  1.  ;;        Date of most recent procedure: ______________________________________
  1.  ;;^TOF^
  1.  ;;    ___ Other therapeutic treatment
  1.  ;;        If checked, describe treatment: _____________________________________
  1.  ;;        Date of completion of treatment or anticipated date of completion:
  1.  ;;        _____________________________________________________________________
  1.  ;;
  1.  ;; d. Does the Veteran currently have any residual conditions or complications
  1.  ;; due to the neoplasm (including metastases) or its treatment, other than
  1.  ;; those already documented in the report above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, list residual conditions and complications (brief summary):
  1.  ;;_____________________________________________________________________________
  1.  ;;
  1.  ;; e. If there are additional benign or malignant neoplasms or metastases
  1.  ;; related to any of the diagnoses in the Diagnosis section, describe using the
  1.  ;; above format: ______________________________________________________________
  1.  ;;
  1.  ;; 6. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, are any of the scars painful and/or unstable, or is the total area
  1.  ;; of all related scars greater than 39 square cm (6 square inches)?
  1.  ;;     ___ Yes   ___ No
  1.  ;;     If yes, also complete a Scars Questionnaire.
  1.  ;;
  1.  ;; b. Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs or symptoms related to any conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): __________________________________________
  1.  ;;
  1.  ;; 7. Mental health manifestations due to CNS condition or its treatment
  1.  ;;
  1.  ;; a. Does the Veteran have depression, cognitive impairment or dementia, or
  1.  ;; any other mental health conditions attributable to a CNS disease and/or its
  1.  ;; treatment?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; b. Does the Veteran's mental health condition(s), as identified in the
  1.  ;; question above, result in gross impairment in thought processes or
  1.  ;; communication?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If No, also complete a Mental Health Questionnaire (schedule with
  1.  ;;     appropriate provider).
  1.  ;;     If yes, briefly describe the Veteran's mental health condition:
  1.  ;;     ________________________________________________________________________
  1.  ;;^TOF^
  1.  ;; 8.  Differentiation of Symptoms or Neurologic Effects
  1.  ;;
  1.  ;; Are you able to differentiate what portion of the symptomotology or
  1.  ;; neurologic effects above are caused by each diagnosis?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, list which symptoms or neurologic effects are attributable to each
  1.  ;; diagnosis, where possible: _________________________________________________
  1.  ;;
  1.  ;; 9. Assistive devices
  1.  ;;
  1.  ;; a. Does the Veteran use any assistive device(s) as a normal mode of
  1.  ;; locomotion, although occasional locomotion by other methods may be possible?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, identify assistive device(s) used (check all that apply and indicate
  1.  ;; frequency):
  1.  ;;   __ Wheelchair  Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Brace(s)    Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Crutch(es)  Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Cane(s)     Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Walker      Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;   __ Other: ________________________________________________________________
  1.  ;;                  Frequency of use:  __ Occasional   __ Regular   __ Constant
  1.  ;;
  1.  ;; b. If the Veteran uses any assistive devices, specify the condition and
  1.  ;; identify the assistive device used for each condition: _____________________
  1.  ;;
  1.  ;; 10. Remaining effective function of the extremities
  1.  ;;
  1.  ;; Due to a CNS condition, is there functional impairment of an extremity such
  1.  ;; that no effective function remains other than that which would be equally
  1.  ;; well served by an amputation with prosthesis? (Functions of the upper
  1.  ;; extremity include grasping, manipulation, etc., while functions for the
  1.  ;; lower extremity include balance and propulsion, etc.)
  1.  ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
  1.  ;;     equally serve the Veteran.
  1.  ;; ___ No
  1.  ;;    If yes, indicate extremity(ies) (check all extremities for which this
  1.  ;;    applies):
  1.  ;;    ___ Right upper    ___ Left upper     ___ Right lower    ___ Left lower
  1.  ;;    For each checked extremity, describe loss of effective function, identify
  1.  ;;    the condition causing loss of function, and provide specific examples
  1.  ;;    (brief summary): ________________________________________________________
  1.  ;;
  1.  ;; 11. Diagnostic testing
  1.  ;;
  1.  ;; NOTE: If the results of MRI, other imaging studies or other diagnostic tests
  1.  ;; are in the medical record and reflect the Veteran's current condition,
  1.  ;; repeat testing is not required. If pulmonary function testing (PFT) is
  1.  ;;^TOF^
  1.  ;; indicated due to respiratory disability, and results are in the medical
  1.  ;; record and reflect the Veteran's current respiratory function, repeat
  1.  ;; testing is not required. DLCO and bronchodilator testing is not indicated
  1.  ;; for a restrictive respiratory disability such as that caused by muscle
  1.  ;; weakness due to CNS conditions.
  1.  ;;
  1.  ;; a. Have imaging studies been performed?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide most recent results, if available: _________________________
  1.  ;;
  1.  ;; b. Have PFTs been performed?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide most recent results, if available:
  1.  ;; FEV-1: ____________ % predicted    Date of test: _____________
  1.  ;; FEV-1/FVC: _______  % predicted    Date of test: _____________
  1.  ;; FVC: _____________  % predicted    Date of test: _____________
  1.  ;;
  1.  ;; c. If PFTs have been performed, is the flow-volume loop compatible with
  1.  ;; upper airway obstruction?
  1.  ;; ___ Yes ___ No
  1.  ;;
  1.  ;; d. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 12. Functional impact
  1.  ;;
  1.  ;; Do the Veteran's central nervous system disorders impact his or her ability
  1.  ;; to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe impact of each of the Veteran's central nervous system
  1.  ;; disorder condition(s), providing one or more examples: _____________________
  1.  ;;_____________________________________________________________________________
  1.  ;;
  1.  ;; 13. Remarks, if any:  ______________________________________________________
  1.  ;;
  1.  ;; Physician signature: ____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: _________________________________ Phone: ___________
  1.  ;;
  1.  ;; Medical license #: ______________________________________ FAX: _____________
  1.  ;;
  1.  ;; Physician address: _________________________________________________________
  1.  ;; 
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's
  1.  ;; application.
  1.  ;;^END^
  1.  Q