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Routine: DVBCQDN3

DVBCQDN3.m

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  1. DVBCQDN3 ;;ALB-CIOFO/ECF - DIABETIC NEUROPATHY QUESTIONNAIRE ; 6/15/2010
  1.  ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
  1.  ;
  1. TXT ;
  1.  ;;^TOF^
  1.  ;; 5. Severity
  1.  ;;
  1.  ;; NOTE: Based on symptoms and findings from Sections 3 and 4, complete items
  1.  ;; a and b below to provide an evaluation of the severity of the Veteran's
  1.  ;; diabetic peripheral neuropathy.
  1.  ;;
  1.  ;; NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree
  1.  ;; of lost or impaired function substantially less than the description of
  1.  ;; complete paralysis that is given with each nerve.
  1.  ;;
  1.  ;; If the nerve is completely paralyzed, check the box for "complete paralysis."
  1.  ;; If the nerve is not completely paralyzed, check the box for "incomplete 
  1.  ;; paralysis" and indicate severity.  For VA purposes, when nerve impairment is
  1.  ;; wholly sensory, the evaluation should be mild, or at most, moderate.
  1.  ;;
  1.  ;; a. Does the Veteran have an upper extremity diabetic peripheral neuropathy?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate nerve affected, severity and side affected:
  1.  ;;
  1.  ;;    Radial nerve (musculospiral nerve) 
  1.  ;;    Note: Complete paralysis(hand and fingers drop, wrist and fingers flexed;
  1.  ;;          cannot extend hand at wrist, extend proximal phalanges of fingers,
  1.  ;;          extend thumb or make lateral movement of wrist; supination of hand,
  1.  ;;          elbow extension and flexion weak, hand grip impaired)
  1.  ;;
  1.  ;;       ___ Right:
  1.  ;;           ___ Normal   ___Incomplete paralysis   ___ Complete paralysis
  1.  ;;           If incomplete paralysis is checked, indicate severity:
  1.  ;;               ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;       ___ Left:
  1.  ;;           ___ Normal   ___ Incomplete paralysis  ___ Complete paralysis
  1.  ;;           If incomplete paralysis is checked, indicate severity:
  1.  ;;               ___ Mild   ___ Moderate   ___ Severe 
  1.  ;;
  1.  ;;    Median nerve
  1.  ;;    Note:  Complete paralysis (hand inclined to the ulnar side, index and
  1.  ;;           middle fingers extended, atrophy of thenar eminence, cannot
  1.  ;;           make fist, defective opposition of thumb, cannot flex distal
  1.  ;;           phalanx of thumb; wrist flexion weak)
  1.  ;;
  1.  ;;       ___ Right:
  1.  ;;           ___ Normal   ___ Incomplete paralysis  ___ Complete paralysis
  1.  ;;           If incomplete paralysis is checked, indicate severity:
  1.  ;;               ___ Mild   ___ Moderate   ___ Severe
  1.  ;;^TOF^
  1.  ;;       ___ Left:
  1.  ;;           ___ Normal   ___ Incomplete paralysis  ___ Complete paralysis
  1.  ;;           If incomplete paralysis is checked, indicate severity:
  1.  ;;               ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;    Ulnar nerve
  1.  ;;    Note:  Complete paralysis ("griffin claw" deformity, atrophy in dorsal
  1.  ;;           interspaces, thenar and hypothenar eminences; cannot extend ring
  1.  ;;           and little finger, cannot spread fingers, cannot adduct the
  1.  ;;           thumb; wrist flexion weakened).
  1.  ;;
  1.  ;;       ___ Right:
  1.  ;;           ___ Normal   ___ Incomplete paralysis  ___ Complete paralysis
  1.  ;;           If incomplete paralysis is checked, indicate severity:
  1.  ;;               ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;       ___ Left:
  1.  ;;           ___ Normal   ___ Incomplete paralysis  ___ Complete paralysis
  1.  ;;           If incomplete paralysis is checked, indicate severity:
  1.  ;;               ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;; b. Does the Veteran have a lower extremity diabetic peripheral neuropathy?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;;  If yes, indicate nerve affected, severity and side affected:
  1.  ;;
  1.  ;;  Sciatic nerve
  1.  ;;  Note: Complete paralysis (foot dangles and drops, no active movement of
  1.  ;;        muscles below the knee, flexion of knee weakened or lost).
  1.  ;;
  1.  ;;       ___ Right:
  1.  ;;           ___ Normal   ___ Incomplete paralysis  ___ Complete paralysis
  1.  ;;           If incomplete paralysis is checked, indicate severity:
  1.  ;;               ___ Mild   ___ Moderate   ___ Moderately severe
  1.  ;;               ___ Severe, with marked muscular atrophy
  1.  ;;
  1.  ;;       ___ Left:
  1.  ;;           ___ Normal   ___ Incomplete paralysis  ___ Complete paralysis
  1.  ;;           If incomplete paralysis is checked, indicate severity:
  1.  ;;               ___ Mild   ___ Moderate   ___ Moderately severe
  1.  ;;               ___ Severe, with marked muscular atrophy
  1.  ;;^TOF^
  1.  ;;   ___ Femoral nerve (anterior crural)
  1.  ;;       Note: Complete paralysis (paralysis of quadriceps extensor muscles).
  1.  ;;
  1.  ;;       ___ Right:
  1.  ;;           ___ Normal   ___ Incomplete paralysis  ___ Complete paralysis
  1.  ;;               ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;       ___ Left:
  1.  ;;           ___ Normal   ___ Incomplete paralysis  ___ Complete paralysis
  1.  ;;           If incomplete paralysis is checked, indicate severity:
  1.  ;;               ___ Mild   ___ Moderate   ___ Severe
  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 and/or symptoms related to any conditions
  1.  ;;  listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe (brief summary): __________________________________________
  1.  ;;
  1.  ;; 7. Diagnostic testing
  1.  ;;
  1.  ;; For purpose of this examination, electromyography (EMG) studies are rarely
  1.  ;; required to diagnose diabetic peripheral neuropathy. The diagnosis of
  1.  ;; diabetic peripheral neuropathy can be made in the appropriate clinical
  1.  ;; setting by a history of characteristic pain and/or sensory changes in a
  1.  ;; stocking/glove distribution and objective clinical findings, which may
  1.  ;; include symmetrical lost/decreased reflexes, decreased strength,
  1.  ;; lost/decreased sensation for cold, vibration and/or position sense, and/or
  1.  ;; lost/decreased sensation to monofilament testing.
  1.  ;;^TOF^
  1.  ;; a. Have EMG studies been performed?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;;    Extremities tested:
  1.  ;;       Right upper extremity  Results:  __ Normal  __ Abnormal   Date: ______
  1.  ;;       Left upper extremity   Results:  __ Normal  __ Abnormal   Date: ______
  1.  ;;       Right lower extremity  Results:  __ Normal  __ Abnormal   Date: ______
  1.  ;;       Left lower extremity   Results:  __ Normal  __ Abnormal   Date: ______
  1.  ;;
  1.  ;; If abnormal, describe: _____________________________________________________
  1.  ;;
  1.  ;; b. If there are other significant findings or diagnostic test results,
  1.  ;; provide dates and describe: ________________________________________________
  1.  ;;
  1.  ;; 8. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's diabetic peripheral neuropathy impact his or her ability
  1.  ;; to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe impact of the Veteran's diabetic peripheral neuropathy,
  1.  ;; providing one or more examples: ____________________________________________
  1.  ;;
  1.  ;; 9. 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.  ;;
  1.  ;;^END^
  1.  Q