DVBCQCN3 ;;ALB-CIOFO/ECF - CENTRAL NERVOUS SYSTEM QUESTIONNAIRE ; 6/20/2011
;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
;
TXT ;
;;
;; d. Deep tendon reflexes (DTRs)
;; Rate reflexes according to the following scale:
;; 0 Absent
;; 1+ Decreased
;; 2+ Normal
;; 3+ Increased without clonus
;; 4+ Increased with clonus
;;
;; ___ All normal
;; Biceps: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Triceps: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Brachioradialis: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; 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+
;;
;; e. Does the Veteran have muscle atrophy attributable to a CNS condition?
;; ___ Yes ___ No
;; If muscle atrophy is present, indicate location: ___________________________
;; When possible, provide difference measured in cm between normal and
;; atrophied side, measured at maximum muscle bulk: _____ cm.
;;^TOF^
;; f. Summary of muscle weakness in the upper and/or lower extremities
;; attributable to a CNS condition (check all that apply):
;; Right upper extremity muscle weakness:
;; ___ None ___ Mild ___ Moderate ___ Severe ___ With atrophy
;; ___ Complete (no remaining function)
;; Left upper extremity muscle weakness:
;; ___ None ___ Mild ___ Moderate ___ Severe ___ With atrophy
;; ___ Complete (no remaining function)
;; Right lower extremity muscle weakness:
;; ___ None ___ Mild ___ Moderate ___ Severe ___ With atrophy
;; ___ Complete (no remaining function)
;; Left lower extremity muscle weakness:
;; ___ None ___ Mild ___ Moderate ___ Severe ___ With atrophy
;; ___ Complete (no remaining function)
;; NOTE: If the Veteran has more than one medical condition contributing to the
;; muscle weakness, identify the condition(s) and describe each condition's
;; contribution to the muscle weakness: _______________________________________
;;
;; 5. Tumors and neoplasms
;;
;; a. Does the Veteran have a benign or malignant neoplasm or metastases
;; related to any of the diagnoses in the Diagnosis section?
;; ___ Yes ___ No
;; If yes, complete the following:
;;
;; b. Is the neoplasm:
;; ___ Benign ___ Malignant
;;
;; c. Has the Veteran completed treatment or is the Veteran currently
;; undergoing treatment for a benign or malignant neoplasm or metastases?
;; ___ Yes ___ No; watchful waiting
;; If yes, indicate type of treatment the Veteran is currently undergoing
;; or has completed (check all that apply):
;; ___ Treatment completed; currently in watchful waiting status
;; ___ Surgery
;; If checked, describe: _______________________________________________
;; Date(s) of surgery: _________________________________________________
;; ___ Radiation therapy
;; Date of most recent treatment: ______________________________________
;; Date of completion of treatment or anticipated date of completion:
;; _____________________________________________________________________
;; ___ Antineoplastic chemotherapy
;; Date of most recent treatment: ______________________________________
;; Date of completion of treatment or anticipated date of completion:
;; _____________________________________________________________________
;; ___ Other therapeutic procedure
;; If checked, describe procedure: _____________________________________
;; Date of most recent procedure: ______________________________________
;;^TOF^
;; ___ Other therapeutic treatment
;; If checked, describe treatment: _____________________________________
;; Date of completion of treatment or anticipated date of completion:
;; _____________________________________________________________________
;;
;; d. Does the Veteran currently have any residual conditions or complications
;; due to the neoplasm (including metastases) or its treatment, other than
;; those already documented in the report above?
;; ___ Yes ___ No
;; If yes, list residual conditions and complications (brief summary):
;;_____________________________________________________________________________
;;
;; e. If there are additional benign or malignant neoplasms or metastases
;; related to any of the diagnoses in the Diagnosis section, describe using the
;; above format: ______________________________________________________________
;;
;; 6. 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 related to any conditions
;; listed in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): __________________________________________
;;
;; 7. Mental health manifestations due to CNS condition or its treatment
;;
;; a. Does the Veteran have depression, cognitive impairment or dementia, or
;; any other mental health conditions attributable to a CNS disease and/or its
;; treatment?
;; ___ Yes ___ No
;;
;; b. Does the Veteran's mental health condition(s), as identified in the
;; question above, result in gross impairment in thought processes or
;; communication?
;; ___ Yes ___ No
;; If No, also complete a Mental Health Questionnaire (schedule with
;; appropriate provider).
;; If yes, briefly describe the Veteran's mental health condition:
;; ________________________________________________________________________
;;^TOF^
;; 8. Differentiation of Symptoms or Neurologic Effects
;;
;; Are you able to differentiate what portion of the symptomotology or
;; neurologic effects above are caused by each diagnosis?
;; ___ Yes ___ No
;; If yes, list which symptoms or neurologic effects are attributable to each
;; diagnosis, where possible: _________________________________________________
;;
;; 9. 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: _____________________
;;
;; 10. Remaining effective function of the extremities
;;
;; Due to a CNS 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., while functions for 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 upper ___ Left upper ___ Right lower ___ Left lower
;; For each checked extremity, describe loss of effective function, identify
;; the condition causing loss of function, and provide specific examples
;; (brief summary): ________________________________________________________
;;
;; 11. Diagnostic testing
;;
;; NOTE: If the results of MRI, other imaging studies or other diagnostic tests
;; are in the medical record and reflect the Veteran's current condition,
;; repeat testing is not required. If pulmonary function testing (PFT) is
;;^TOF^
;; indicated due to respiratory disability, and results are in the medical
;; record and reflect the Veteran's current respiratory function, repeat
;; testing is not required. DLCO and bronchodilator testing is not indicated
;; for a restrictive respiratory disability such as that caused by muscle
;; weakness due to CNS conditions.
;;
;; a. Have imaging studies been performed?
;; ___ Yes ___ No
;; If yes, provide most recent results, if available: _________________________
;;
;; b. Have PFTs been performed?
;; ___ Yes ___ No
;; If yes, provide most recent results, if available:
;; FEV-1: ____________ % predicted Date of test: _____________
;; FEV-1/FVC: _______ % predicted Date of test: _____________
;; FVC: _____________ % predicted Date of test: _____________
;;
;; c. If PFTs have been performed, is the flow-volume loop compatible with
;; upper airway obstruction?
;; ___ Yes ___ No
;;
;; d. 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):
;; ____________________________________________________________________________
;;
;; 12. Functional impact
;;
;; Do the Veteran's central nervous system disorders impact his or her ability
;; to work?
;; ___ Yes ___ No
;; If yes, describe impact of each of the Veteran's central nervous system
;; disorder condition(s), providing one or more examples: _____________________
;;_____________________________________________________________________________
;;
;; 13. Remarks, if any: ______________________________________________________
;;
;; Physician signature: ____________________________________ Date: ____________
;;
;; Physician printed name: _________________________________ Phone: ___________
;;
;; Medical license #: ______________________________________ FAX: _____________
;;
;; Physician address: _________________________________________________________
;;
;; 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[HDVBCQCN3 11588 printed Apr 09, 2024@20:52:47 Page 2
DVBCQCN3 ;;ALB-CIOFO/ECF - CENTRAL NERVOUS SYSTEM QUESTIONNAIRE ; 6/20/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;;
+2 ;; d. Deep tendon reflexes (DTRs)
+3 ;; Rate reflexes according to the following scale:
+4 ;; 0 Absent
+5 ;; 1+ Decreased
+6 ;; 2+ Normal
+7 ;; 3+ Increased without clonus
+8 ;; 4+ Increased with clonus
+9 ;;
+10 ;; ___ All normal
+11 ;; Biceps: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+12 ;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+13 ;; Triceps: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+14 ;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+15 ;; Brachioradialis: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+16 ;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+17 ;; Knee: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+18 ;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+19 ;; Ankle: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+20 ;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+21 ;;
+22 ;; e. Does the Veteran have muscle atrophy attributable to a CNS condition?
+23 ;; ___ Yes ___ No
+24 ;; If muscle atrophy is present, indicate location: ___________________________
+25 ;; When possible, provide difference measured in cm between normal and
+26 ;; atrophied side, measured at maximum muscle bulk: _____ cm.
+27 ;;^TOF^
+28 ;; f. Summary of muscle weakness in the upper and/or lower extremities
+29 ;; attributable to a CNS condition (check all that apply):
+30 ;; Right upper extremity muscle weakness:
+31 ;; ___ None ___ Mild ___ Moderate ___ Severe ___ With atrophy
+32 ;; ___ Complete (no remaining function)
+33 ;; Left upper extremity muscle weakness:
+34 ;; ___ None ___ Mild ___ Moderate ___ Severe ___ With atrophy
+35 ;; ___ Complete (no remaining function)
+36 ;; Right lower extremity muscle weakness:
+37 ;; ___ None ___ Mild ___ Moderate ___ Severe ___ With atrophy
+38 ;; ___ Complete (no remaining function)
+39 ;; Left lower extremity muscle weakness:
+40 ;; ___ None ___ Mild ___ Moderate ___ Severe ___ With atrophy
+41 ;; ___ Complete (no remaining function)
+42 ;; NOTE: If the Veteran has more than one medical condition contributing to the
+43 ;; muscle weakness, identify the condition(s) and describe each condition's
+44 ;; contribution to the muscle weakness: _______________________________________
+45 ;;
+46 ;; 5. Tumors and neoplasms
+47 ;;
+48 ;; a. Does the Veteran have a benign or malignant neoplasm or metastases
+49 ;; related to any of the diagnoses in the Diagnosis section?
+50 ;; ___ Yes ___ No
+51 ;; If yes, complete the following:
+52 ;;
+53 ;; b. Is the neoplasm:
+54 ;; ___ Benign ___ Malignant
+55 ;;
+56 ;; c. Has the Veteran completed treatment or is the Veteran currently
+57 ;; undergoing treatment for a benign or malignant neoplasm or metastases?
+58 ;; ___ Yes ___ No; watchful waiting
+59 ;; If yes, indicate type of treatment the Veteran is currently undergoing
+60 ;; or has completed (check all that apply):
+61 ;; ___ Treatment completed; currently in watchful waiting status
+62 ;; ___ Surgery
+63 ;; If checked, describe: _______________________________________________
+64 ;; Date(s) of surgery: _________________________________________________
+65 ;; ___ Radiation therapy
+66 ;; Date of most recent treatment: ______________________________________
+67 ;; Date of completion of treatment or anticipated date of completion:
+68 ;; _____________________________________________________________________
+69 ;; ___ Antineoplastic chemotherapy
+70 ;; Date of most recent treatment: ______________________________________
+71 ;; Date of completion of treatment or anticipated date of completion:
+72 ;; _____________________________________________________________________
+73 ;; ___ Other therapeutic procedure
+74 ;; If checked, describe procedure: _____________________________________
+75 ;; Date of most recent procedure: ______________________________________
+76 ;;^TOF^
+77 ;; ___ Other therapeutic treatment
+78 ;; If checked, describe treatment: _____________________________________
+79 ;; Date of completion of treatment or anticipated date of completion:
+80 ;; _____________________________________________________________________
+81 ;;
+82 ;; d. Does the Veteran currently have any residual conditions or complications
+83 ;; due to the neoplasm (including metastases) or its treatment, other than
+84 ;; those already documented in the report above?
+85 ;; ___ Yes ___ No
+86 ;; If yes, list residual conditions and complications (brief summary):
+87 ;;_____________________________________________________________________________
+88 ;;
+89 ;; e. If there are additional benign or malignant neoplasms or metastases
+90 ;; related to any of the diagnoses in the Diagnosis section, describe using the
+91 ;; above format: ______________________________________________________________
+92 ;;
+93 ;; 6. Other pertinent physical findings, complications, conditions, signs
+94 ;; and/or symptoms
+95 ;;
+96 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+97 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+98 ;; section above?
+99 ;; ___ Yes ___ No
+100 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+101 ;; of all related scars greater than 39 square cm (6 square inches)?
+102 ;; ___ Yes ___ No
+103 ;; If yes, also complete a Scars Questionnaire.
+104 ;;
+105 ;; b. Does the Veteran have any other pertinent physical findings,
+106 ;; complications, conditions, signs or symptoms related to any conditions
+107 ;; listed in the Diagnosis section above?
+108 ;; ___ Yes ___ No
+109 ;; If yes, describe (brief summary): __________________________________________
+110 ;;
+111 ;; 7. Mental health manifestations due to CNS condition or its treatment
+112 ;;
+113 ;; a. Does the Veteran have depression, cognitive impairment or dementia, or
+114 ;; any other mental health conditions attributable to a CNS disease and/or its
+115 ;; treatment?
+116 ;; ___ Yes ___ No
+117 ;;
+118 ;; b. Does the Veteran's mental health condition(s), as identified in the
+119 ;; question above, result in gross impairment in thought processes or
+120 ;; communication?
+121 ;; ___ Yes ___ No
+122 ;; If No, also complete a Mental Health Questionnaire (schedule with
+123 ;; appropriate provider).
+124 ;; If yes, briefly describe the Veteran's mental health condition:
+125 ;; ________________________________________________________________________
+126 ;;^TOF^
+127 ;; 8. Differentiation of Symptoms or Neurologic Effects
+128 ;;
+129 ;; Are you able to differentiate what portion of the symptomotology or
+130 ;; neurologic effects above are caused by each diagnosis?
+131 ;; ___ Yes ___ No
+132 ;; If yes, list which symptoms or neurologic effects are attributable to each
+133 ;; diagnosis, where possible: _________________________________________________
+134 ;;
+135 ;; 9. Assistive devices
+136 ;;
+137 ;; a. Does the Veteran use any assistive device(s) as a normal mode of
+138 ;; locomotion, although occasional locomotion by other methods may be possible?
+139 ;; ___ Yes ___ No
+140 ;;
+141 ;; If yes, identify assistive device(s) used (check all that apply and indicate
+142 ;; frequency):
+143 ;; __ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
+144 ;; __ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
+145 ;; __ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
+146 ;; __ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
+147 ;; __ Walker Frequency of use: __ Occasional __ Regular __ Constant
+148 ;; __ Other: ________________________________________________________________
+149 ;; Frequency of use: __ Occasional __ Regular __ Constant
+150 ;;
+151 ;; b. If the Veteran uses any assistive devices, specify the condition and
+152 ;; identify the assistive device used for each condition: _____________________
+153 ;;
+154 ;; 10. Remaining effective function of the extremities
+155 ;;
+156 ;; Due to a CNS condition, is there functional impairment of an extremity such
+157 ;; that no effective function remains other than that which would be equally
+158 ;; well served by an amputation with prosthesis? (Functions of the upper
+159 ;; extremity include grasping, manipulation, etc., while functions for the
+160 ;; lower extremity include balance and propulsion, etc.)
+161 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+162 ;; equally serve the Veteran.
+163 ;; ___ No
+164 ;; If yes, indicate extremity(ies) (check all extremities for which this
+165 ;; applies):
+166 ;; ___ Right upper ___ Left upper ___ Right lower ___ Left lower
+167 ;; For each checked extremity, describe loss of effective function, identify
+168 ;; the condition causing loss of function, and provide specific examples
+169 ;; (brief summary): ________________________________________________________
+170 ;;
+171 ;; 11. Diagnostic testing
+172 ;;
+173 ;; NOTE: If the results of MRI, other imaging studies or other diagnostic tests
+174 ;; are in the medical record and reflect the Veteran's current condition,
+175 ;; repeat testing is not required. If pulmonary function testing (PFT) is
+176 ;;^TOF^
+177 ;; indicated due to respiratory disability, and results are in the medical
+178 ;; record and reflect the Veteran's current respiratory function, repeat
+179 ;; testing is not required. DLCO and bronchodilator testing is not indicated
+180 ;; for a restrictive respiratory disability such as that caused by muscle
+181 ;; weakness due to CNS conditions.
+182 ;;
+183 ;; a. Have imaging studies been performed?
+184 ;; ___ Yes ___ No
+185 ;; If yes, provide most recent results, if available: _________________________
+186 ;;
+187 ;; b. Have PFTs been performed?
+188 ;; ___ Yes ___ No
+189 ;; If yes, provide most recent results, if available:
+190 ;; FEV-1: ____________ % predicted Date of test: _____________
+191 ;; FEV-1/FVC: _______ % predicted Date of test: _____________
+192 ;; FVC: _____________ % predicted Date of test: _____________
+193 ;;
+194 ;; c. If PFTs have been performed, is the flow-volume loop compatible with
+195 ;; upper airway obstruction?
+196 ;; ___ Yes ___ No
+197 ;;
+198 ;; d. Are there any other significant diagnostic test findings and/or results?
+199 ;; ___ Yes ___ No
+200 ;; If yes, provide type of test or procedure, date and results (brief summary):
+201 ;; ____________________________________________________________________________
+202 ;;
+203 ;; 12. Functional impact
+204 ;;
+205 ;; Do the Veteran's central nervous system disorders impact his or her ability
+206 ;; to work?
+207 ;; ___ Yes ___ No
+208 ;; If yes, describe impact of each of the Veteran's central nervous system
+209 ;; disorder condition(s), providing one or more examples: _____________________
+210 ;;_____________________________________________________________________________
+211 ;;
+212 ;; 13. Remarks, if any: ______________________________________________________
+213 ;;
+214 ;; Physician signature: ____________________________________ Date: ____________
+215 ;;
+216 ;; Physician printed name: _________________________________ Phone: ___________
+217 ;;
+218 ;; Medical license #: ______________________________________ FAX: _____________
+219 ;;
+220 ;; Physician address: _________________________________________________________
+221 ;;
+222 ;; NOTE: VA may request additional medical information, including additional
+223 ;; examinations if necessary to complete VA's review of the Veteran's
+224 ;; application.
+225 ;;^END^
+226 QUIT
