DVBCQDN2 ;;ALB-CIOFO/ECF - DIABETIC NEUROPATHY QUESTIONNAIRE ; 6/15/2010
;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
;
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 diabetic
;; peripheral neuropathy?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to diabetic peripheral
;; neuropathy:
;;
;; Diagnosis #1: ____________________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; Diagnosis #2: ____________________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; Diagnosis #3: ____________________
;; ICD code: ________________________
;; Date of diagnosis: _______________
;;
;; If there are additional diagnoses that pertain to diabetic peripheral
;; neuropathy, list using above format: _______________________________________
;;
;; 2. Medical history
;;
;; a. Does the Veteran have diabetes mellitus type I or type II?
;; ___ Yes ___ No
;;
;; b. Describe the history (including cause, onset and course) the Veteran's
;; diabetic peripheral neuropathy: ____________________________________________
;;
;; c. Dominant hand
;; ___ Right ___ Left ___ Ambidextrous
;;^TOF^
;; 3. Symptoms
;;
;; a. Does the Veteran have any symptoms attributable to diabetic peripheral
;; neuropathy?
;; ___ Yes ___ No
;;
;; If yes, indicate symptoms' location and severity (check all that apply):
;;
;; Constant pain (may be excruciating at times)
;; Right upper extremity: __ None __ Mild __ Moderate __ Severe
;; Left upper extremity: __ None __ Mild __ Moderate __ Severe
;; Right lower extremity: __ None __ Mild __ Moderate __ Severe
;; Left lower extremity: __ None __ Mild __ Moderate __ Severe
;;
;; Intermittent pain (usually dull)
;; Right upper extremity: __ None __ Mild __ Moderate __ Severe
;; Left upper extremity: __ None __ Mild __ Moderate __ Severe
;; Right lower extremity: __ None __ Mild __ Moderate __ Severe
;; Left lower extremity: __ None __ Mild __ Moderate __ Severe
;;
;; Paresthesias and/or dysesthesias
;; Right upper extremity: __ None __ Mild __ Moderate __ Severe
;; Left upper extremity: __ None __ Mild __ Moderate __ Severe
;; Right lower extremity: __ None __ Mild __ Moderate __ Severe
;; Left lower extremity: __ None __ Mild __ Moderate __ Severe
;;
;; Numbness
;; Right upper extremity: __ None __ Mild __ Moderate __ Severe
;; Left upper extremity: __ None __ Mild __ Moderate __ Severe
;; Right lower extremity: __ None __ Mild __ Moderate __ Severe
;; Left lower extremity: __ None __ Mild __ Moderate __ Severe
;;
;; b. ___ Other symptoms (describe symptoms, location and severity): __________
;;
;; ____________________________________________________________________________
;;
;;^TOF^
;; 4. Neurologic exam
;;
;; a. 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
;;
;; 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
;;
;; Knee 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 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
;;^TOF^
;; b. 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+
;;
;; c. Light touch/monofilament testing results:
;;
;; ___ All normal
;; Shoulder area: Right: __ Normal __ Decreased __ Absent
;; Left: __ Normal __ Decreased __ Absent
;; Inner/outer forearm:
;; Right: __ Normal __ Decreased __ Absent
;; Left: __ Normal __ Decreased __ Absent
;; Hand/fingers: Right: __ Normal __ Decreased __ Absent
;; Left: __ Normal __ Decreased __ Absent
;; Knee/thigh: Right: __ Normal __ Decreased __ Absent
;; Left: __ Normal __ Decreased __ Absent
;; Ankle/lower leg: Right: __ Normal __ Decreased __ Absent
;; Left: __ Normal __ Decreased __ Absent
;; Foot/toes: Right: __ Normal __ Decreased __ Absent
;; Left: __ Normal __ Decreased __ Absent
;;^TOF^
;; d. Position sense (grasp index finger/great toe on sides and ask patient to
;; identify up and down movement)
;;
;; ___ Not tested
;; Right upper extremity: __ Normal __ Decreased __ Absent
;; Left upper extremity: __ Normal __ Decreased __ Absent
;; Right lower extremity: __ Normal __ Decreased __ Absent
;; Left lower extremity: __ Normal __ Decreased __ Absent
;;
;; e. Vibration sensation (place low-pitched tuning fork over DIP joint of index
;; finger/IP joint of great toe)
;;
;; ___ Not tested
;; Right upper extremity: __ Normal __ Decreased __ Absent
;; Left upper extremity: __ Normal __ Decreased __ Absent
;; Right lower extremity: __ Normal __ Decreased __ Absent
;; Left lower extremity: __ Normal __ Decreased __ Absent
;;
;; f. Cold sensation (test distal extremities for cold sensation with side of
;; tuning fork)
;;
;; ___ Not tested
;; Right upper extremity: __ Normal __ Decreased __ Absent
;; Left upper extremity: __ Normal __ Decreased __ Absent
;; Right lower extremity: __ Normal __ Decreased __ Absent
;; Left lower extremity: __ Normal __ Decreased __ Absent
;;
;; g. Does the Veteran have muscle atrophy?
;; ___ Yes ___ No
;;
;; If muscle atrophy is present, indicate location: ________________________
;; For each instance of muscle atrophy, provide measurements in cm between
;; normal and atrophied side, measured at maximum muscle bulk: _________ cm.
;;
;; h. Does the Veteran have trophic changes (characterized by loss of extremity
;; hair, smooth, shiny skin, etc.) attributable to diabetic peripheral
;; neuropathy?
;; ___ Yes ___ No
;;
;; If yes, describe: __________________________________________________________
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQDN2 9443 printed Apr 09, 2024@20:59:11 Page 2
DVBCQDN2 ;;ALB-CIOFO/ECF - DIABETIC NEUROPATHY QUESTIONNAIRE ; 6/15/2010
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran now have or has he/she ever been diagnosed with diabetic
+10 ;; peripheral neuropathy?
+11 ;; ___ Yes ___ No
+12 ;;
+13 ;; If yes, provide only diagnoses that pertain to diabetic peripheral
+14 ;; neuropathy:
+15 ;;
+16 ;; Diagnosis #1: ____________________
+17 ;; ICD code: ________________________
+18 ;; Date of diagnosis: _______________
+19 ;;
+20 ;; Diagnosis #2: ____________________
+21 ;; ICD code: ________________________
+22 ;; Date of diagnosis: _______________
+23 ;;
+24 ;; Diagnosis #3: ____________________
+25 ;; ICD code: ________________________
+26 ;; Date of diagnosis: _______________
+27 ;;
+28 ;; If there are additional diagnoses that pertain to diabetic peripheral
+29 ;; neuropathy, list using above format: _______________________________________
+30 ;;
+31 ;; 2. Medical history
+32 ;;
+33 ;; a. Does the Veteran have diabetes mellitus type I or type II?
+34 ;; ___ Yes ___ No
+35 ;;
+36 ;; b. Describe the history (including cause, onset and course) the Veteran's
+37 ;; diabetic peripheral neuropathy: ____________________________________________
+38 ;;
+39 ;; c. Dominant hand
+40 ;; ___ Right ___ Left ___ Ambidextrous
+41 ;;^TOF^
+42 ;; 3. Symptoms
+43 ;;
+44 ;; a. Does the Veteran have any symptoms attributable to diabetic peripheral
+45 ;; neuropathy?
+46 ;; ___ Yes ___ No
+47 ;;
+48 ;; If yes, indicate symptoms' location and severity (check all that apply):
+49 ;;
+50 ;; Constant pain (may be excruciating at times)
+51 ;; Right upper extremity: __ None __ Mild __ Moderate __ Severe
+52 ;; Left upper extremity: __ None __ Mild __ Moderate __ Severe
+53 ;; Right lower extremity: __ None __ Mild __ Moderate __ Severe
+54 ;; Left lower extremity: __ None __ Mild __ Moderate __ Severe
+55 ;;
+56 ;; Intermittent pain (usually dull)
+57 ;; Right upper extremity: __ None __ Mild __ Moderate __ Severe
+58 ;; Left upper extremity: __ None __ Mild __ Moderate __ Severe
+59 ;; Right lower extremity: __ None __ Mild __ Moderate __ Severe
+60 ;; Left lower extremity: __ None __ Mild __ Moderate __ Severe
+61 ;;
+62 ;; Paresthesias and/or dysesthesias
+63 ;; Right upper extremity: __ None __ Mild __ Moderate __ Severe
+64 ;; Left upper extremity: __ None __ Mild __ Moderate __ Severe
+65 ;; Right lower extremity: __ None __ Mild __ Moderate __ Severe
+66 ;; Left lower extremity: __ None __ Mild __ Moderate __ Severe
+67 ;;
+68 ;; Numbness
+69 ;; Right upper extremity: __ None __ Mild __ Moderate __ Severe
+70 ;; Left upper extremity: __ None __ Mild __ Moderate __ Severe
+71 ;; Right lower extremity: __ None __ Mild __ Moderate __ Severe
+72 ;; Left lower extremity: __ None __ Mild __ Moderate __ Severe
+73 ;;
+74 ;; b. ___ Other symptoms (describe symptoms, location and severity): __________
+75 ;;
+76 ;; ____________________________________________________________________________
+77 ;;
+78 ;;^TOF^
+79 ;; 4. Neurologic exam
+80 ;;
+81 ;; a. Strength
+82 ;; Rate strength according to the following scale:
+83 ;; 0/5 No muscle movement
+84 ;; 1/5 Visible muscle movement, but no joint movement
+85 ;; 2/5 No movement against gravity
+86 ;; 3/5 No movement against resistance
+87 ;; 4/5 Less than normal strength
+88 ;; 5/5 Normal strength
+89 ;;
+90 ;; ___ All normal
+91 ;;
+92 ;; Elbow flexion: Right: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+93 ;; Left: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+94 ;;
+95 ;; Elbow extension: Right: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+96 ;; Left: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+97 ;;
+98 ;; Wrist flexion: Right: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+99 ;; Left: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+100 ;;
+101 ;; Wrist extension: Right: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+102 ;; Left: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+103 ;;
+104 ;; Grip: Right: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+105 ;; Left: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+106 ;;
+107 ;; Pinch (thumb to index finger):
+108 ;; Right: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+109 ;; Left: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+110 ;;
+111 ;; Knee extension: Right: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+112 ;; Left: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+113 ;;
+114 ;; Knee flexion: Right: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+115 ;; Left: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+116 ;;
+117 ;; Ankle plantar flexion:
+118 ;; Right: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+119 ;; Left: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+120 ;;
+121 ;; Ankle dorsiflexion:
+122 ;; Right: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+123 ;; Left: __ 5/5 __ 4/5 __ 3/5 __ 2/5 __ 1/5 __ 0/5
+124 ;;^TOF^
+125 ;; b. Deep tendon reflexes (DTRs)
+126 ;; Rate reflexes according to the following scale:
+127 ;; 0 Absent
+128 ;; 1+ Decreased
+129 ;; 2+ Normal
+130 ;; 3+ Increased without clonus
+131 ;; 4+ Increased with clonus
+132 ;;
+133 ;; ___ All normal
+134 ;; Biceps: Right: __ 0 __ 1+ __ 2+ __ 3+ __ 4+
+135 ;; Left: __ 0 __ 1+ __ 2+ __ 3+ __ 4+
+136 ;; Triceps: Right: __ 0 __ 1+ __ 2+ __ 3+ __ 4+
+137 ;; Left: __ 0 __ 1+ __ 2+ __ 3+ __ 4+
+138 ;; Brachioradialis: Right: __ 0 __ 1+ __ 2+ __ 3+ __ 4+
+139 ;; Left: __ 0 __ 1+ __ 2+ __ 3+ __ 4+
+140 ;; Knee: Right: __ 0 __ 1+ __ 2+ __ 3+ __ 4+
+141 ;; Left: __ 0 __ 1+ __ 2+ __ 3+ __ 4+
+142 ;; Ankle: Right: __ 0 __ 1+ __ 2+ __ 3+ __ 4+
+143 ;; Left: __ 0 __ 1+ __ 2+ __ 3+ __ 4+
+144 ;;
+145 ;; c. Light touch/monofilament testing results:
+146 ;;
+147 ;; ___ All normal
+148 ;; Shoulder area: Right: __ Normal __ Decreased __ Absent
+149 ;; Left: __ Normal __ Decreased __ Absent
+150 ;; Inner/outer forearm:
+151 ;; Right: __ Normal __ Decreased __ Absent
+152 ;; Left: __ Normal __ Decreased __ Absent
+153 ;; Hand/fingers: Right: __ Normal __ Decreased __ Absent
+154 ;; Left: __ Normal __ Decreased __ Absent
+155 ;; Knee/thigh: Right: __ Normal __ Decreased __ Absent
+156 ;; Left: __ Normal __ Decreased __ Absent
+157 ;; Ankle/lower leg: Right: __ Normal __ Decreased __ Absent
+158 ;; Left: __ Normal __ Decreased __ Absent
+159 ;; Foot/toes: Right: __ Normal __ Decreased __ Absent
+160 ;; Left: __ Normal __ Decreased __ Absent
+161 ;;^TOF^
+162 ;; d. Position sense (grasp index finger/great toe on sides and ask patient to
+163 ;; identify up and down movement)
+164 ;;
+165 ;; ___ Not tested
+166 ;; Right upper extremity: __ Normal __ Decreased __ Absent
+167 ;; Left upper extremity: __ Normal __ Decreased __ Absent
+168 ;; Right lower extremity: __ Normal __ Decreased __ Absent
+169 ;; Left lower extremity: __ Normal __ Decreased __ Absent
+170 ;;
+171 ;; e. Vibration sensation (place low-pitched tuning fork over DIP joint of index
+172 ;; finger/IP joint of great toe)
+173 ;;
+174 ;; ___ Not tested
+175 ;; Right upper extremity: __ Normal __ Decreased __ Absent
+176 ;; Left upper extremity: __ Normal __ Decreased __ Absent
+177 ;; Right lower extremity: __ Normal __ Decreased __ Absent
+178 ;; Left lower extremity: __ Normal __ Decreased __ Absent
+179 ;;
+180 ;; f. Cold sensation (test distal extremities for cold sensation with side of
+181 ;; tuning fork)
+182 ;;
+183 ;; ___ Not tested
+184 ;; Right upper extremity: __ Normal __ Decreased __ Absent
+185 ;; Left upper extremity: __ Normal __ Decreased __ Absent
+186 ;; Right lower extremity: __ Normal __ Decreased __ Absent
+187 ;; Left lower extremity: __ Normal __ Decreased __ Absent
+188 ;;
+189 ;; g. Does the Veteran have muscle atrophy?
+190 ;; ___ Yes ___ No
+191 ;;
+192 ;; If muscle atrophy is present, indicate location: ________________________
+193 ;; For each instance of muscle atrophy, provide measurements in cm between
+194 ;; normal and atrophied side, measured at maximum muscle bulk: _________ cm.
+195 ;;
+196 ;; h. Does the Veteran have trophic changes (characterized by loss of extremity
+197 ;; hair, smooth, shiny skin, etc.) attributable to diabetic peripheral
+198 ;; neuropathy?
+199 ;; ___ Yes ___ No
+200 ;;
+201 ;; If yes, describe: __________________________________________________________
+202 ;;
+203 QUIT
