DVBCQEL2 ;;ALB-CIOFO/ECF - ELBOW AND FOREARM QUESTIONNAIRE ; 2/15/2011
;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
;
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 had an elbow or forearm
;; condition?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to elbow and forearm
;; conditions:
;; Diagnosis #1: __________________
;; ICD code: _____________________
;; Date of diagnosis: _____________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; Diagnosis #2: __________________
;; ICD code: _____________________
;; Date of diagnosis: _____________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; Diagnosis #3: __________________
;; ICD code: _____________________
;; Date of diagnosis: _____________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; If there are additional diagnoses that pertain to elbow and forearm
;; conditions, list using above format: _______________________________________
;;
;; 2. Medical history
;; a. Describe the history (including onset and course) of the Veteran's
;; elbow and forearm condition (brief summary): _______________________________
;;_____________________________________________________________________________
;;
;; b. Dominant hand:
;; ___ Right ___ Left ___ Ambidextrous
;;
;; 3. Flare-ups
;; Does the Veteran report that flare-ups impact the function of the elbow
;; and/or forearm?
;; ___ Yes ___ No
;; If yes, document the Veteran's description of the impact of flare-ups in
;; his or her own words: ______________________________________________________
;;
;; 4. Initial range of motion (ROM) measurements
;; Measure ROM with a goniometer, rounding each measurement to the nearest
;; 5 degrees. During the measurements, document the point at which painful
;; motion begins, evidenced by visible behavior such as facial expression,
;; wincing, etc. Report initial measurements below.
;;
;; Following the initial assessment of ROM, perform repetitive use testing.
;; For VA purposes, repetitive use testing must be included in all joint
;; exams. The VA has determined that 3 repetitions of ROM (at a minimum) can
;; serve as a representative test of the effect of repetitive use. After the
;; initial measurement, reassess ROM after 3 repetitions. Report post-test
;; measurements in section 5.
;;
;; a. Right elbow flexion
;; Select where flexion ends (normal endpoint is 145 degrees):
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
;; ___135 ___140 ___145 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
;; ___135 ___140 ___145 or greater
;;
;; b. Right elbow extension
;; Select where extension ends:
;; ___0 or any degree of hyperextension (no limitation of extension)
;; Unable to fully extend; extension ends at:
;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
;; ___95 ___100 ___105 ___110 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___ 0 or any degree of hyperextension (no limitation of extension)
;; Unable to fully extend; extension ends at:
;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
;; ___95 ___100 ___105 ___110 or greater
;;
;; c. Left elbow flexion
;; Select where flexion ends (normal endpoint is 145 degrees):
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
;; ___135 ___140 ___145 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
;; ___135 ___140 ___145 or greater
;;^TOF^
;; d. Left elbow extension
;; Select where extension ends:
;; ___ 0 or any degree of hyperextension (no limitation of extension)
;; Unable to fully extend; extension ends at:
;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
;; ___95 ___100 ___105 ___110 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___ 0 or any degree of hyperextension (no limitation of extension)
;; Unable to fully extend; extension ends at:
;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
;; ___95 ___100 ___105 ___110 or greater
;;
;; e. If ROM does not conform to the normal range of motion identified above
;; but is normal for this Veteran (for reasons other than an elbow condition,
;; such as age, body habitus, neurologic disease), explain: ___________________
;;
;; 5. ROM measurements after repetitive use testing
;; a. Is the Veteran able to perform repetitive-use testing with 3
;; repetitions?
;; ___ Yes ___ No If unable, provide reason: _____________________________
;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
;; If Veteran is able to perform repetitive-use testing, measure and report
;; ROM after a minimum of 3 repetitions:
;;
;; b. Right elbow post-test ROM
;; Select where post-test flexion ends:
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
;; ___135 ___140 ___145 or greater
;;
;; Select where post-test extension ends:
;; ___ 0 or any degree of hyperextension (no limitation of extension)
;; Unable to fully extend; extension ends at:
;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
;; ___95 ___100 ___105 ___110 or greater
;;^TOF^
;; c. Left elbow post-test ROM
;; Select where post-test flexion ends:
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
;; ___135 ___140 ___145 or greater
;;
;; Select where post-test extension ends:
;; ___ 0 or any degree of hyperextension (no limitation of extension)
;; Unable to fully extend; extension ends at:
;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
;; ___95 ___100 ___105 ___110 or greater
;;
;; 6. Functional loss and additional limitation in ROM
;; The following section addresses reasons for functional loss, if present,
;; and additional loss of ROM after repetitive-use testing, if present. The
;; VA defines functional loss as the inability to perform normal working
;; movements of the body with normal excursion, strength, speed, coordination
;; and/or endurance.
;;
;; a. Does the Veteran have additional limitation in ROM of the elbow and
;; forearm following repetitive-use testing?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have any functional loss and/or functional impairment
;; of the elbow and forearm?
;; ___ Yes ___ No
;;
;; c. If the Veteran has functional loss, functional impairment and/or
;; additional limitation of ROM of the elbow and forearm after repetitive use,
;; indicate the contributing factors of disability below (check all that apply
;; and indicate side affected):
;; ___ No functional loss for right upper extremity
;; ___ No functional loss for left upper extremity
;; ___ Less movement than normal ___ Right ___ Left ___ Both
;; ___ More movement than normal ___ Right ___ Left ___ Both
;; ___ Weakened movement ___ Right ___ Left ___ Both
;; ___ Excess fatigability ___ Right ___ Left ___ Both
;; ___ Incoordination, impaired ability to execute
;; skilled movements smoothly ___ Right ___ Left ___ Both
;; ___ Pain on movement ___ Right ___ Left ___ Both
;; ___ Swelling ___ Right ___ Left ___ Both
;; ___ Deformity ___ Right ___ Left ___ Both
;; ___ Atrophy of disuse ___ Right ___ Left ___ Both
;;^TOF^
;; 7. Pain (pain on palpation)
;; Does the Veteran have localized tenderness or pain on palpation of
;; joints/soft tissue of either elbow or forearm?
;; ___ Yes ___ No
;; If yes, side affected: ___ Right ___ Left ___ Both
;;
;; 8. Muscle strength testing
;; Rate strength according to the following scale:
;; 0/5 No muscle movement
;; 1/5 Palpable or visible muscle contraction, but no joint movement
;; 2/5 Active movement with gravity eliminated
;; 3/5 Active movement against gravity
;; 4/5 Active movement against some resistance
;; 5/5 Normal strength
;; 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
;;
;; 9. Ankylosis
;; Does the Veteran have ankylosis of the elbow?
;; ___ Yes ___ No
;; If yes, indicate side and severity:
;; ___ At an angle of more than 90 degrees ___ Right ___ Left ___ Both
;; ___ At an angle between 90 and 70 degrees ___ Right ___ Left ___ Both
;; ___ At an angle between 70 and 50 degrees ___ Right ___ Left ___ Both
;; ___ At an angle of less than 50 degrees ___ Right ___ Left ___ Both
;;
;; 10. Additional conditions:
;; Does the Veteran have flail joint, joint fracture and/or impairment of
;; supination or pronation?
;; ___ Yes ___ No
;; If yes, indicate condition and complete the appropriate sections below.
;;
;; a. ___ Flail joint of the elbow
;; If checked, indicate side: ___ Right ___ Left ___ Both
;;
;; b. ___ Intra-articular fracture (joint fracture) with marked varus or
;; valgus deformity?
;; If checked, indicate side: ___ Right ___ Left ___ Both
;;
;; c. ___ Intra-articular fracture (joint fracture) with ununited fracture of
;; the head of the radius?
;; If checked, indicate side: ___ Right ___ Left ___ Both
;;^TOF^
;; d. ___ Impairment of supination or pronation
;; If checked, indicate severity and side
;; ___ Supination limited to 30 degrees or less
;; ___ Right ___ Left ___ Both
;; ___ Limited pronation with motion lost beyond the last quarter
;; of the arc; hand does not approach full pronation
;; ___ Right ___ Left ___ Both
;; ___ Limited pronation with motion lost beyond the middle of the arc
;; ___ Right ___ Left ___ Both
;; ___ Hand is fixed near the middle of the arc or moderate pronation due
;; to bone fusion
;; ___ Right ___ Left ___ Both
;; ___ Hand fixed in full pronation due to bone fusion
;; ___ Right ___ Left ___ Both
;; ___ Hand fixed in supination or hyperpronation due to bone fusion
;; ___ Right ___ Left ___ Both
;;
;; 11. Joint replacement and other surgical procedures
;; a. Has the Veteran had a total elbow joint replacement?
;; ___ Yes ___ No
;; If yes, indicate side and severity of residuals.
;; ___ Right elbow
;; Date of surgery: ___________________
;; Residuals:
;; ___ None
;; ___ Intermediate degrees of residual weakness, pain and/or
;; limitation of motion
;; ___ Chronic residuals consisting of severe painful motion and/or
;; weakness
;; ___ Other, describe: _____________
;; ___ Left elbow
;; Date of surgery: ___________________
;; Residuals:
;; ___ None
;; ___ Intermediate degrees of residual weakness, pain or limitation
;; of motion
;; ___ Chronic residuals consisting of severe painful motion or
;; weakness
;; ___ Other, describe: _____________________________________________
;;
;; b. Has the Veteran had arthroscopic or other elbow surgery?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; Date and type of surgery: _____________
;;
;; c. Does the Veteran have any residual signs and/or symptoms due to
;; arthroscopic or other elbow surgery?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; If yes, describe residuals: _____________________________________________
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQEL2 14425 printed Dec 13, 2024@01:46:08 Page 2
DVBCQEL2 ;;ALB-CIOFO/ECF - ELBOW AND FOREARM QUESTIONNAIRE ; 2/15/2011
+1 ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;;
+5 ;; 1. Diagnosis
+6 ;; Does the Veteran now have or has he/she ever had an elbow or forearm
+7 ;; condition?
+8 ;; ___ Yes ___ No
+9 ;;
+10 ;; If yes, provide only diagnoses that pertain to elbow and forearm
+11 ;; conditions:
+12 ;; Diagnosis #1: __________________
+13 ;; ICD code: _____________________
+14 ;; Date of diagnosis: _____________
+15 ;; Side affected: ___ Right ___ Left ___ Both
+16 ;;
+17 ;; Diagnosis #2: __________________
+18 ;; ICD code: _____________________
+19 ;; Date of diagnosis: _____________
+20 ;; Side affected: ___ Right ___ Left ___ Both
+21 ;;
+22 ;; Diagnosis #3: __________________
+23 ;; ICD code: _____________________
+24 ;; Date of diagnosis: _____________
+25 ;; Side affected: ___ Right ___ Left ___ Both
+26 ;;
+27 ;; If there are additional diagnoses that pertain to elbow and forearm
+28 ;; conditions, list using above format: _______________________________________
+29 ;;
+30 ;; 2. Medical history
+31 ;; a. Describe the history (including onset and course) of the Veteran's
+32 ;; elbow and forearm condition (brief summary): _______________________________
+33 ;;_____________________________________________________________________________
+34 ;;
+35 ;; b. Dominant hand:
+36 ;; ___ Right ___ Left ___ Ambidextrous
+37 ;;
+38 ;; 3. Flare-ups
+39 ;; Does the Veteran report that flare-ups impact the function of the elbow
+40 ;; and/or forearm?
+41 ;; ___ Yes ___ No
+42 ;; If yes, document the Veteran's description of the impact of flare-ups in
+43 ;; his or her own words: ______________________________________________________
+44 ;;
+45 ;; 4. Initial range of motion (ROM) measurements
+46 ;; Measure ROM with a goniometer, rounding each measurement to the nearest
+47 ;; 5 degrees. During the measurements, document the point at which painful
+48 ;; motion begins, evidenced by visible behavior such as facial expression,
+49 ;; wincing, etc. Report initial measurements below.
+50 ;;
+51 ;; Following the initial assessment of ROM, perform repetitive use testing.
+52 ;; For VA purposes, repetitive use testing must be included in all joint
+53 ;; exams. The VA has determined that 3 repetitions of ROM (at a minimum) can
+54 ;; serve as a representative test of the effect of repetitive use. After the
+55 ;; initial measurement, reassess ROM after 3 repetitions. Report post-test
+56 ;; measurements in section 5.
+57 ;;
+58 ;; a. Right elbow flexion
+59 ;; Select where flexion ends (normal endpoint is 145 degrees):
+60 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
+61 ;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
+62 ;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
+63 ;; ___135 ___140 ___145 or greater
+64 ;;
+65 ;; Select where objective evidence of painful motion begins:
+66 ;; ___ No objective evidence of painful motion
+67 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
+68 ;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
+69 ;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
+70 ;; ___135 ___140 ___145 or greater
+71 ;;
+72 ;; b. Right elbow extension
+73 ;; Select where extension ends:
+74 ;; ___0 or any degree of hyperextension (no limitation of extension)
+75 ;; Unable to fully extend; extension ends at:
+76 ;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
+77 ;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
+78 ;; ___95 ___100 ___105 ___110 or greater
+79 ;;
+80 ;; Select where objective evidence of painful motion begins:
+81 ;; ___ No objective evidence of painful motion
+82 ;; ___ 0 or any degree of hyperextension (no limitation of extension)
+83 ;; Unable to fully extend; extension ends at:
+84 ;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
+85 ;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
+86 ;; ___95 ___100 ___105 ___110 or greater
+87 ;;
+88 ;; c. Left elbow flexion
+89 ;; Select where flexion ends (normal endpoint is 145 degrees):
+90 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
+91 ;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
+92 ;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
+93 ;; ___135 ___140 ___145 or greater
+94 ;;
+95 ;; Select where objective evidence of painful motion begins:
+96 ;; ___ No objective evidence of painful motion
+97 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
+98 ;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
+99 ;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
+100 ;; ___135 ___140 ___145 or greater
+101 ;;^TOF^
+102 ;; d. Left elbow extension
+103 ;; Select where extension ends:
+104 ;; ___ 0 or any degree of hyperextension (no limitation of extension)
+105 ;; Unable to fully extend; extension ends at:
+106 ;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
+107 ;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
+108 ;; ___95 ___100 ___105 ___110 or greater
+109 ;;
+110 ;; Select where objective evidence of painful motion begins:
+111 ;; ___ No objective evidence of painful motion
+112 ;; ___ 0 or any degree of hyperextension (no limitation of extension)
+113 ;; Unable to fully extend; extension ends at:
+114 ;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
+115 ;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
+116 ;; ___95 ___100 ___105 ___110 or greater
+117 ;;
+118 ;; e. If ROM does not conform to the normal range of motion identified above
+119 ;; but is normal for this Veteran (for reasons other than an elbow condition,
+120 ;; such as age, body habitus, neurologic disease), explain: ___________________
+121 ;;
+122 ;; 5. ROM measurements after repetitive use testing
+123 ;; a. Is the Veteran able to perform repetitive-use testing with 3
+124 ;; repetitions?
+125 ;; ___ Yes ___ No If unable, provide reason: _____________________________
+126 ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
+127 ;; If Veteran is able to perform repetitive-use testing, measure and report
+128 ;; ROM after a minimum of 3 repetitions:
+129 ;;
+130 ;; b. Right elbow post-test ROM
+131 ;; Select where post-test flexion ends:
+132 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
+133 ;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
+134 ;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
+135 ;; ___135 ___140 ___145 or greater
+136 ;;
+137 ;; Select where post-test extension ends:
+138 ;; ___ 0 or any degree of hyperextension (no limitation of extension)
+139 ;; Unable to fully extend; extension ends at:
+140 ;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
+141 ;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
+142 ;; ___95 ___100 ___105 ___110 or greater
+143 ;;^TOF^
+144 ;; c. Left elbow post-test ROM
+145 ;; Select where post-test flexion ends:
+146 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
+147 ;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
+148 ;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
+149 ;; ___135 ___140 ___145 or greater
+150 ;;
+151 ;; Select where post-test extension ends:
+152 ;; ___ 0 or any degree of hyperextension (no limitation of extension)
+153 ;; Unable to fully extend; extension ends at:
+154 ;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
+155 ;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
+156 ;; ___95 ___100 ___105 ___110 or greater
+157 ;;
+158 ;; 6. Functional loss and additional limitation in ROM
+159 ;; The following section addresses reasons for functional loss, if present,
+160 ;; and additional loss of ROM after repetitive-use testing, if present. The
+161 ;; VA defines functional loss as the inability to perform normal working
+162 ;; movements of the body with normal excursion, strength, speed, coordination
+163 ;; and/or endurance.
+164 ;;
+165 ;; a. Does the Veteran have additional limitation in ROM of the elbow and
+166 ;; forearm following repetitive-use testing?
+167 ;; ___ Yes ___ No
+168 ;;
+169 ;; b. Does the Veteran have any functional loss and/or functional impairment
+170 ;; of the elbow and forearm?
+171 ;; ___ Yes ___ No
+172 ;;
+173 ;; c. If the Veteran has functional loss, functional impairment and/or
+174 ;; additional limitation of ROM of the elbow and forearm after repetitive use,
+175 ;; indicate the contributing factors of disability below (check all that apply
+176 ;; and indicate side affected):
+177 ;; ___ No functional loss for right upper extremity
+178 ;; ___ No functional loss for left upper extremity
+179 ;; ___ Less movement than normal ___ Right ___ Left ___ Both
+180 ;; ___ More movement than normal ___ Right ___ Left ___ Both
+181 ;; ___ Weakened movement ___ Right ___ Left ___ Both
+182 ;; ___ Excess fatigability ___ Right ___ Left ___ Both
+183 ;; ___ Incoordination, impaired ability to execute
+184 ;; skilled movements smoothly ___ Right ___ Left ___ Both
+185 ;; ___ Pain on movement ___ Right ___ Left ___ Both
+186 ;; ___ Swelling ___ Right ___ Left ___ Both
+187 ;; ___ Deformity ___ Right ___ Left ___ Both
+188 ;; ___ Atrophy of disuse ___ Right ___ Left ___ Both
+189 ;;^TOF^
+190 ;; 7. Pain (pain on palpation)
+191 ;; Does the Veteran have localized tenderness or pain on palpation of
+192 ;; joints/soft tissue of either elbow or forearm?
+193 ;; ___ Yes ___ No
+194 ;; If yes, side affected: ___ Right ___ Left ___ Both
+195 ;;
+196 ;; 8. Muscle strength testing
+197 ;; Rate strength according to the following scale:
+198 ;; 0/5 No muscle movement
+199 ;; 1/5 Palpable or visible muscle contraction, but no joint movement
+200 ;; 2/5 Active movement with gravity eliminated
+201 ;; 3/5 Active movement against gravity
+202 ;; 4/5 Active movement against some resistance
+203 ;; 5/5 Normal strength
+204 ;; Elbow flexion:
+205 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+206 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+207 ;; Elbow extension:
+208 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+209 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+210 ;;
+211 ;; 9. Ankylosis
+212 ;; Does the Veteran have ankylosis of the elbow?
+213 ;; ___ Yes ___ No
+214 ;; If yes, indicate side and severity:
+215 ;; ___ At an angle of more than 90 degrees ___ Right ___ Left ___ Both
+216 ;; ___ At an angle between 90 and 70 degrees ___ Right ___ Left ___ Both
+217 ;; ___ At an angle between 70 and 50 degrees ___ Right ___ Left ___ Both
+218 ;; ___ At an angle of less than 50 degrees ___ Right ___ Left ___ Both
+219 ;;
+220 ;; 10. Additional conditions:
+221 ;; Does the Veteran have flail joint, joint fracture and/or impairment of
+222 ;; supination or pronation?
+223 ;; ___ Yes ___ No
+224 ;; If yes, indicate condition and complete the appropriate sections below.
+225 ;;
+226 ;; a. ___ Flail joint of the elbow
+227 ;; If checked, indicate side: ___ Right ___ Left ___ Both
+228 ;;
+229 ;; b. ___ Intra-articular fracture (joint fracture) with marked varus or
+230 ;; valgus deformity?
+231 ;; If checked, indicate side: ___ Right ___ Left ___ Both
+232 ;;
+233 ;; c. ___ Intra-articular fracture (joint fracture) with ununited fracture of
+234 ;; the head of the radius?
+235 ;; If checked, indicate side: ___ Right ___ Left ___ Both
+236 ;;^TOF^
+237 ;; d. ___ Impairment of supination or pronation
+238 ;; If checked, indicate severity and side
+239 ;; ___ Supination limited to 30 degrees or less
+240 ;; ___ Right ___ Left ___ Both
+241 ;; ___ Limited pronation with motion lost beyond the last quarter
+242 ;; of the arc; hand does not approach full pronation
+243 ;; ___ Right ___ Left ___ Both
+244 ;; ___ Limited pronation with motion lost beyond the middle of the arc
+245 ;; ___ Right ___ Left ___ Both
+246 ;; ___ Hand is fixed near the middle of the arc or moderate pronation due
+247 ;; to bone fusion
+248 ;; ___ Right ___ Left ___ Both
+249 ;; ___ Hand fixed in full pronation due to bone fusion
+250 ;; ___ Right ___ Left ___ Both
+251 ;; ___ Hand fixed in supination or hyperpronation due to bone fusion
+252 ;; ___ Right ___ Left ___ Both
+253 ;;
+254 ;; 11. Joint replacement and other surgical procedures
+255 ;; a. Has the Veteran had a total elbow joint replacement?
+256 ;; ___ Yes ___ No
+257 ;; If yes, indicate side and severity of residuals.
+258 ;; ___ Right elbow
+259 ;; Date of surgery: ___________________
+260 ;; Residuals:
+261 ;; ___ None
+262 ;; ___ Intermediate degrees of residual weakness, pain and/or
+263 ;; limitation of motion
+264 ;; ___ Chronic residuals consisting of severe painful motion and/or
+265 ;; weakness
+266 ;; ___ Other, describe: _____________
+267 ;; ___ Left elbow
+268 ;; Date of surgery: ___________________
+269 ;; Residuals:
+270 ;; ___ None
+271 ;; ___ Intermediate degrees of residual weakness, pain or limitation
+272 ;; of motion
+273 ;; ___ Chronic residuals consisting of severe painful motion or
+274 ;; weakness
+275 ;; ___ Other, describe: _____________________________________________
+276 ;;
+277 ;; b. Has the Veteran had arthroscopic or other elbow surgery?
+278 ;; ___ Yes ___ No
+279 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+280 ;; Date and type of surgery: _____________
+281 ;;
+282 ;; c. Does the Veteran have any residual signs and/or symptoms due to
+283 ;; arthroscopic or other elbow surgery?
+284 ;; ___ Yes ___ No
+285 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+286 ;; If yes, describe residuals: _____________________________________________
+287 ;;
+288 QUIT
