- 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 Feb 18, 2025@23:12:24 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
