DVBCQDN3 ;;ALB-CIOFO/ECF - DIABETIC NEUROPATHY QUESTIONNAIRE ; 6/15/2010
;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
;
TXT ;
;;^TOF^
;; 5. Severity
;;
;; NOTE: Based on symptoms and findings from Sections 3 and 4, complete items
;; a and b below to provide an evaluation of the severity of the Veteran's
;; diabetic peripheral neuropathy.
;;
;; NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree
;; of lost or impaired function substantially less than the description of
;; complete paralysis that is given with each nerve.
;;
;; If the nerve is completely paralyzed, check the box for "complete paralysis."
;; If the nerve is not completely paralyzed, check the box for "incomplete
;; paralysis" and indicate severity. For VA purposes, when nerve impairment is
;; wholly sensory, the evaluation should be mild, or at most, moderate.
;;
;; a. Does the Veteran have an upper extremity diabetic peripheral neuropathy?
;; ___ Yes ___ No
;; If yes, indicate nerve affected, severity and side affected:
;;
;; Radial nerve (musculospiral nerve)
;; Note: Complete paralysis(hand and fingers drop, wrist and fingers flexed;
;; cannot extend hand at wrist, extend proximal phalanges of fingers,
;; extend thumb or make lateral movement of wrist; supination of hand,
;; elbow extension and flexion weak, hand grip impaired)
;;
;; ___ Right:
;; ___ Normal ___Incomplete paralysis ___ Complete paralysis
;; If incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; ___ Left:
;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
;; If incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; Median nerve
;; Note: Complete paralysis (hand inclined to the ulnar side, index and
;; middle fingers extended, atrophy of thenar eminence, cannot
;; make fist, defective opposition of thumb, cannot flex distal
;; phalanx of thumb; wrist flexion weak)
;;
;; ___ Right:
;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
;; If incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;^TOF^
;; ___ Left:
;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
;; If incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; Ulnar nerve
;; Note: Complete paralysis ("griffin claw" deformity, atrophy in dorsal
;; interspaces, thenar and hypothenar eminences; cannot extend ring
;; and little finger, cannot spread fingers, cannot adduct the
;; thumb; wrist flexion weakened).
;;
;; ___ Right:
;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
;; If incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; ___ Left:
;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
;; If incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; b. Does the Veteran have a lower extremity diabetic peripheral neuropathy?
;; ___ Yes ___ No
;;
;; If yes, indicate nerve affected, severity and side affected:
;;
;; Sciatic nerve
;; Note: Complete paralysis (foot dangles and drops, no active movement of
;; muscles below the knee, flexion of knee weakened or lost).
;;
;; ___ Right:
;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
;; If incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Moderately severe
;; ___ Severe, with marked muscular atrophy
;;
;; ___ Left:
;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
;; If incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Moderately severe
;; ___ Severe, with marked muscular atrophy
;;^TOF^
;; ___ Femoral nerve (anterior crural)
;; Note: Complete paralysis (paralysis of quadriceps extensor muscles).
;;
;; ___ Right:
;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
;; ___ Mild ___ Moderate ___ Severe
;;
;; ___ Left:
;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
;; If incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Severe
;;
;; 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 and/or symptoms related to any conditions
;; listed in the Diagnosis section above?
;; ___ Yes ___ No
;;
;; If yes, describe (brief summary): __________________________________________
;;
;; 7. Diagnostic testing
;;
;; For purpose of this examination, electromyography (EMG) studies are rarely
;; required to diagnose diabetic peripheral neuropathy. The diagnosis of
;; diabetic peripheral neuropathy can be made in the appropriate clinical
;; setting by a history of characteristic pain and/or sensory changes in a
;; stocking/glove distribution and objective clinical findings, which may
;; include symmetrical lost/decreased reflexes, decreased strength,
;; lost/decreased sensation for cold, vibration and/or position sense, and/or
;; lost/decreased sensation to monofilament testing.
;;^TOF^
;; a. Have EMG studies been performed?
;; ___ Yes ___ No
;;
;; Extremities tested:
;; Right upper extremity Results: __ Normal __ Abnormal Date: ______
;; Left upper extremity Results: __ Normal __ Abnormal Date: ______
;; Right lower extremity Results: __ Normal __ Abnormal Date: ______
;; Left lower extremity Results: __ Normal __ Abnormal Date: ______
;;
;; If abnormal, describe: _____________________________________________________
;;
;; b. If there are other significant findings or diagnostic test results,
;; provide dates and describe: ________________________________________________
;;
;; 8. Functional impact
;;
;; Does the Veteran's diabetic peripheral neuropathy impact his or her ability
;; to work?
;; ___ Yes ___ No
;; If yes, describe impact of the Veteran's diabetic peripheral neuropathy,
;; providing one or more examples: ____________________________________________
;;
;; 9. 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[HDVBCQDN3 7994 printed Apr 09, 2024@20:57:43 Page 2
DVBCQDN3 ;;ALB-CIOFO/ECF - DIABETIC NEUROPATHY QUESTIONNAIRE ; 6/15/2010
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;;^TOF^
+2 ;; 5. Severity
+3 ;;
+4 ;; NOTE: Based on symptoms and findings from Sections 3 and 4, complete items
+5 ;; a and b below to provide an evaluation of the severity of the Veteran's
+6 ;; diabetic peripheral neuropathy.
+7 ;;
+8 ;; NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree
+9 ;; of lost or impaired function substantially less than the description of
+10 ;; complete paralysis that is given with each nerve.
+11 ;;
+12 ;; If the nerve is completely paralyzed, check the box for "complete paralysis."
+13 ;; If the nerve is not completely paralyzed, check the box for "incomplete
+14 ;; paralysis" and indicate severity. For VA purposes, when nerve impairment is
+15 ;; wholly sensory, the evaluation should be mild, or at most, moderate.
+16 ;;
+17 ;; a. Does the Veteran have an upper extremity diabetic peripheral neuropathy?
+18 ;; ___ Yes ___ No
+19 ;; If yes, indicate nerve affected, severity and side affected:
+20 ;;
+21 ;; Radial nerve (musculospiral nerve)
+22 ;; Note: Complete paralysis(hand and fingers drop, wrist and fingers flexed;
+23 ;; cannot extend hand at wrist, extend proximal phalanges of fingers,
+24 ;; extend thumb or make lateral movement of wrist; supination of hand,
+25 ;; elbow extension and flexion weak, hand grip impaired)
+26 ;;
+27 ;; ___ Right:
+28 ;; ___ Normal ___Incomplete paralysis ___ Complete paralysis
+29 ;; If incomplete paralysis is checked, indicate severity:
+30 ;; ___ Mild ___ Moderate ___ Severe
+31 ;;
+32 ;; ___ Left:
+33 ;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
+34 ;; If incomplete paralysis is checked, indicate severity:
+35 ;; ___ Mild ___ Moderate ___ Severe
+36 ;;
+37 ;; Median nerve
+38 ;; Note: Complete paralysis (hand inclined to the ulnar side, index and
+39 ;; middle fingers extended, atrophy of thenar eminence, cannot
+40 ;; make fist, defective opposition of thumb, cannot flex distal
+41 ;; phalanx of thumb; wrist flexion weak)
+42 ;;
+43 ;; ___ Right:
+44 ;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
+45 ;; If incomplete paralysis is checked, indicate severity:
+46 ;; ___ Mild ___ Moderate ___ Severe
+47 ;;^TOF^
+48 ;; ___ Left:
+49 ;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
+50 ;; If incomplete paralysis is checked, indicate severity:
+51 ;; ___ Mild ___ Moderate ___ Severe
+52 ;;
+53 ;; Ulnar nerve
+54 ;; Note: Complete paralysis ("griffin claw" deformity, atrophy in dorsal
+55 ;; interspaces, thenar and hypothenar eminences; cannot extend ring
+56 ;; and little finger, cannot spread fingers, cannot adduct the
+57 ;; thumb; wrist flexion weakened).
+58 ;;
+59 ;; ___ Right:
+60 ;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
+61 ;; If incomplete paralysis is checked, indicate severity:
+62 ;; ___ Mild ___ Moderate ___ Severe
+63 ;;
+64 ;; ___ Left:
+65 ;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
+66 ;; If incomplete paralysis is checked, indicate severity:
+67 ;; ___ Mild ___ Moderate ___ Severe
+68 ;;
+69 ;; b. Does the Veteran have a lower extremity diabetic peripheral neuropathy?
+70 ;; ___ Yes ___ No
+71 ;;
+72 ;; If yes, indicate nerve affected, severity and side affected:
+73 ;;
+74 ;; Sciatic nerve
+75 ;; Note: Complete paralysis (foot dangles and drops, no active movement of
+76 ;; muscles below the knee, flexion of knee weakened or lost).
+77 ;;
+78 ;; ___ Right:
+79 ;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
+80 ;; If incomplete paralysis is checked, indicate severity:
+81 ;; ___ Mild ___ Moderate ___ Moderately severe
+82 ;; ___ Severe, with marked muscular atrophy
+83 ;;
+84 ;; ___ Left:
+85 ;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
+86 ;; If incomplete paralysis is checked, indicate severity:
+87 ;; ___ Mild ___ Moderate ___ Moderately severe
+88 ;; ___ Severe, with marked muscular atrophy
+89 ;;^TOF^
+90 ;; ___ Femoral nerve (anterior crural)
+91 ;; Note: Complete paralysis (paralysis of quadriceps extensor muscles).
+92 ;;
+93 ;; ___ Right:
+94 ;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
+95 ;; ___ Mild ___ Moderate ___ Severe
+96 ;;
+97 ;; ___ Left:
+98 ;; ___ Normal ___ Incomplete paralysis ___ Complete paralysis
+99 ;; If incomplete paralysis is checked, indicate severity:
+100 ;; ___ Mild ___ Moderate ___ Severe
+101 ;;
+102 ;; 6. Other pertinent physical findings, complications, conditions, signs
+103 ;; and/or symptoms
+104 ;;
+105 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+106 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+107 ;; section above?
+108 ;; ___ Yes ___ No
+109 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+110 ;; of all related scars greater than 39 square cm (6 square inches)?
+111 ;; ___ Yes ___ No
+112 ;; If yes, also complete a Scars Questionnaire.
+113 ;;
+114 ;; b. Does the Veteran have any other pertinent physical findings,
+115 ;; complications, conditions, signs and/or symptoms related to any conditions
+116 ;; listed in the Diagnosis section above?
+117 ;; ___ Yes ___ No
+118 ;;
+119 ;; If yes, describe (brief summary): __________________________________________
+120 ;;
+121 ;; 7. Diagnostic testing
+122 ;;
+123 ;; For purpose of this examination, electromyography (EMG) studies are rarely
+124 ;; required to diagnose diabetic peripheral neuropathy. The diagnosis of
+125 ;; diabetic peripheral neuropathy can be made in the appropriate clinical
+126 ;; setting by a history of characteristic pain and/or sensory changes in a
+127 ;; stocking/glove distribution and objective clinical findings, which may
+128 ;; include symmetrical lost/decreased reflexes, decreased strength,
+129 ;; lost/decreased sensation for cold, vibration and/or position sense, and/or
+130 ;; lost/decreased sensation to monofilament testing.
+131 ;;^TOF^
+132 ;; a. Have EMG studies been performed?
+133 ;; ___ Yes ___ No
+134 ;;
+135 ;; Extremities tested:
+136 ;; Right upper extremity Results: __ Normal __ Abnormal Date: ______
+137 ;; Left upper extremity Results: __ Normal __ Abnormal Date: ______
+138 ;; Right lower extremity Results: __ Normal __ Abnormal Date: ______
+139 ;; Left lower extremity Results: __ Normal __ Abnormal Date: ______
+140 ;;
+141 ;; If abnormal, describe: _____________________________________________________
+142 ;;
+143 ;; b. If there are other significant findings or diagnostic test results,
+144 ;; provide dates and describe: ________________________________________________
+145 ;;
+146 ;; 8. Functional impact
+147 ;;
+148 ;; Does the Veteran's diabetic peripheral neuropathy impact his or her ability
+149 ;; to work?
+150 ;; ___ Yes ___ No
+151 ;; If yes, describe impact of the Veteran's diabetic peripheral neuropathy,
+152 ;; providing one or more examples: ____________________________________________
+153 ;;
+154 ;; 9. Remarks, if any: ________________________________________________________
+155 ;;
+156 ;; Physician signature: ____________________________________ Date: ____________
+157 ;;
+158 ;; Physician printed name: _________________________________ Phone: ___________
+159 ;;
+160 ;; Medical license #: _______________________________________ Fax: ____________
+161 ;;
+162 ;; Physician address: _________________________________________________________
+163 ;;
+164 ;; NOTE: VA may request additional medical information, including additional
+165 ;; examinations if necessary to complete VA's review of the Veteran's
+166 ;; application.
+167 ;;
+168 ;;^END^
+169 QUIT
