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Routine: DVBCQEL2

DVBCQEL2.m

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  1. DVBCQEL2 ;;ALB-CIOFO/ECF - ELBOW AND FOREARM QUESTIONNAIRE ; 2/15/2011
  1. ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
  1. ;
  1. TXT ;
  1. ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1. ;; disability benefits. VA will consider the information you provide on this
  1. ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1. ;;
  1. ;; 1. Diagnosis
  1. ;; Does the Veteran now have or has he/she ever had an elbow or forearm
  1. ;; condition?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, provide only diagnoses that pertain to elbow and forearm
  1. ;; conditions:
  1. ;; Diagnosis #1: __________________
  1. ;; ICD code: _____________________
  1. ;; Date of diagnosis: _____________
  1. ;; Side affected: ___ Right ___ Left ___ Both
  1. ;;
  1. ;; Diagnosis #2: __________________
  1. ;; ICD code: _____________________
  1. ;; Date of diagnosis: _____________
  1. ;; Side affected: ___ Right ___ Left ___ Both
  1. ;;
  1. ;; Diagnosis #3: __________________
  1. ;; ICD code: _____________________
  1. ;; Date of diagnosis: _____________
  1. ;; Side affected: ___ Right ___ Left ___ Both
  1. ;;
  1. ;; If there are additional diagnoses that pertain to elbow and forearm
  1. ;; conditions, list using above format: _______________________________________
  1. ;;
  1. ;; 2. Medical history
  1. ;; a. Describe the history (including onset and course) of the Veteran's
  1. ;; elbow and forearm condition (brief summary): _______________________________
  1. ;;_____________________________________________________________________________
  1. ;;
  1. ;; b. Dominant hand:
  1. ;; ___ Right ___ Left ___ Ambidextrous
  1. ;;
  1. ;; 3. Flare-ups
  1. ;; Does the Veteran report that flare-ups impact the function of the elbow
  1. ;; and/or forearm?
  1. ;; ___ Yes ___ No
  1. ;; If yes, document the Veteran's description of the impact of flare-ups in
  1. ;; his or her own words: ______________________________________________________
  1. ;;
  1. ;; 4. Initial range of motion (ROM) measurements
  1. ;; Measure ROM with a goniometer, rounding each measurement to the nearest
  1. ;; 5 degrees. During the measurements, document the point at which painful
  1. ;; motion begins, evidenced by visible behavior such as facial expression,
  1. ;; wincing, etc. Report initial measurements below.
  1. ;;
  1. ;; Following the initial assessment of ROM, perform repetitive use testing.
  1. ;; For VA purposes, repetitive use testing must be included in all joint
  1. ;; exams. The VA has determined that 3 repetitions of ROM (at a minimum) can
  1. ;; serve as a representative test of the effect of repetitive use. After the
  1. ;; initial measurement, reassess ROM after 3 repetitions. Report post-test
  1. ;; measurements in section 5.
  1. ;;
  1. ;; a. Right elbow flexion
  1. ;; Select where flexion ends (normal endpoint is 145 degrees):
  1. ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
  1. ;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
  1. ;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
  1. ;; ___135 ___140 ___145 or greater
  1. ;;
  1. ;; Select where objective evidence of painful motion begins:
  1. ;; ___ No objective evidence of painful motion
  1. ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
  1. ;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
  1. ;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
  1. ;; ___135 ___140 ___145 or greater
  1. ;;
  1. ;; b. Right elbow extension
  1. ;; Select where extension ends:
  1. ;; ___0 or any degree of hyperextension (no limitation of extension)
  1. ;; Unable to fully extend; extension ends at:
  1. ;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
  1. ;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
  1. ;; ___95 ___100 ___105 ___110 or greater
  1. ;;
  1. ;; Select where objective evidence of painful motion begins:
  1. ;; ___ No objective evidence of painful motion
  1. ;; ___ 0 or any degree of hyperextension (no limitation of extension)
  1. ;; Unable to fully extend; extension ends at:
  1. ;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
  1. ;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
  1. ;; ___95 ___100 ___105 ___110 or greater
  1. ;;
  1. ;; c. Left elbow flexion
  1. ;; Select where flexion ends (normal endpoint is 145 degrees):
  1. ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
  1. ;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
  1. ;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
  1. ;; ___135 ___140 ___145 or greater
  1. ;;
  1. ;; Select where objective evidence of painful motion begins:
  1. ;; ___ No objective evidence of painful motion
  1. ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
  1. ;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
  1. ;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
  1. ;; ___135 ___140 ___145 or greater
  1. ;;^TOF^
  1. ;; d. Left elbow extension
  1. ;; Select where extension ends:
  1. ;; ___ 0 or any degree of hyperextension (no limitation of extension)
  1. ;; Unable to fully extend; extension ends at:
  1. ;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
  1. ;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
  1. ;; ___95 ___100 ___105 ___110 or greater
  1. ;;
  1. ;; Select where objective evidence of painful motion begins:
  1. ;; ___ No objective evidence of painful motion
  1. ;; ___ 0 or any degree of hyperextension (no limitation of extension)
  1. ;; Unable to fully extend; extension ends at:
  1. ;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
  1. ;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
  1. ;; ___95 ___100 ___105 ___110 or greater
  1. ;;
  1. ;; e. If ROM does not conform to the normal range of motion identified above
  1. ;; but is normal for this Veteran (for reasons other than an elbow condition,
  1. ;; such as age, body habitus, neurologic disease), explain: ___________________
  1. ;;
  1. ;; 5. ROM measurements after repetitive use testing
  1. ;; a. Is the Veteran able to perform repetitive-use testing with 3
  1. ;; repetitions?
  1. ;; ___ Yes ___ No If unable, provide reason: _____________________________
  1. ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
  1. ;; If Veteran is able to perform repetitive-use testing, measure and report
  1. ;; ROM after a minimum of 3 repetitions:
  1. ;;
  1. ;; b. Right elbow post-test ROM
  1. ;; Select where post-test flexion ends:
  1. ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
  1. ;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
  1. ;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
  1. ;; ___135 ___140 ___145 or greater
  1. ;;
  1. ;; Select where post-test extension ends:
  1. ;; ___ 0 or any degree of hyperextension (no limitation of extension)
  1. ;; Unable to fully extend; extension ends at:
  1. ;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
  1. ;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
  1. ;; ___95 ___100 ___105 ___110 or greater
  1. ;;^TOF^
  1. ;; c. Left elbow post-test ROM
  1. ;; Select where post-test flexion ends:
  1. ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40
  1. ;; ___45 ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85
  1. ;; ___90 ___95 ___100 ___105 ___110 ___115 ___120 ___125 ___130
  1. ;; ___135 ___140 ___145 or greater
  1. ;;
  1. ;; Select where post-test extension ends:
  1. ;; ___ 0 or any degree of hyperextension (no limitation of extension)
  1. ;; Unable to fully extend; extension ends at:
  1. ;; ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45
  1. ;; ___50 ___55 ___60 ___65 ___70 ___75 ___80 ___85 ___90
  1. ;; ___95 ___100 ___105 ___110 or greater
  1. ;;
  1. ;; 6. Functional loss and additional limitation in ROM
  1. ;; The following section addresses reasons for functional loss, if present,
  1. ;; and additional loss of ROM after repetitive-use testing, if present. The
  1. ;; VA defines functional loss as the inability to perform normal working
  1. ;; movements of the body with normal excursion, strength, speed, coordination
  1. ;; and/or endurance.
  1. ;;
  1. ;; a. Does the Veteran have additional limitation in ROM of the elbow and
  1. ;; forearm following repetitive-use testing?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; b. Does the Veteran have any functional loss and/or functional impairment
  1. ;; of the elbow and forearm?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; c. If the Veteran has functional loss, functional impairment and/or
  1. ;; additional limitation of ROM of the elbow and forearm after repetitive use,
  1. ;; indicate the contributing factors of disability below (check all that apply
  1. ;; and indicate side affected):
  1. ;; ___ No functional loss for right upper extremity
  1. ;; ___ No functional loss for left upper extremity
  1. ;; ___ Less movement than normal ___ Right ___ Left ___ Both
  1. ;; ___ More movement than normal ___ Right ___ Left ___ Both
  1. ;; ___ Weakened movement ___ Right ___ Left ___ Both
  1. ;; ___ Excess fatigability ___ Right ___ Left ___ Both
  1. ;; ___ Incoordination, impaired ability to execute
  1. ;; skilled movements smoothly ___ Right ___ Left ___ Both
  1. ;; ___ Pain on movement ___ Right ___ Left ___ Both
  1. ;; ___ Swelling ___ Right ___ Left ___ Both
  1. ;; ___ Deformity ___ Right ___ Left ___ Both
  1. ;; ___ Atrophy of disuse ___ Right ___ Left ___ Both
  1. ;;^TOF^
  1. ;; 7. Pain (pain on palpation)
  1. ;; Does the Veteran have localized tenderness or pain on palpation of
  1. ;; joints/soft tissue of either elbow or forearm?
  1. ;; ___ Yes ___ No
  1. ;; If yes, side affected: ___ Right ___ Left ___ Both
  1. ;;
  1. ;; 8. Muscle strength testing
  1. ;; Rate strength according to the following scale:
  1. ;; 0/5 No muscle movement
  1. ;; 1/5 Palpable or visible muscle contraction, but no joint movement
  1. ;; 2/5 Active movement with gravity eliminated
  1. ;; 3/5 Active movement against gravity
  1. ;; 4/5 Active movement against some resistance
  1. ;; 5/5 Normal strength
  1. ;; Elbow flexion:
  1. ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
  1. ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
  1. ;; Elbow extension:
  1. ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
  1. ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
  1. ;;
  1. ;; 9. Ankylosis
  1. ;; Does the Veteran have ankylosis of the elbow?
  1. ;; ___ Yes ___ No
  1. ;; If yes, indicate side and severity:
  1. ;; ___ At an angle of more than 90 degrees ___ Right ___ Left ___ Both
  1. ;; ___ At an angle between 90 and 70 degrees ___ Right ___ Left ___ Both
  1. ;; ___ At an angle between 70 and 50 degrees ___ Right ___ Left ___ Both
  1. ;; ___ At an angle of less than 50 degrees ___ Right ___ Left ___ Both
  1. ;;
  1. ;; 10. Additional conditions:
  1. ;; Does the Veteran have flail joint, joint fracture and/or impairment of
  1. ;; supination or pronation?
  1. ;; ___ Yes ___ No
  1. ;; If yes, indicate condition and complete the appropriate sections below.
  1. ;;
  1. ;; a. ___ Flail joint of the elbow
  1. ;; If checked, indicate side: ___ Right ___ Left ___ Both
  1. ;;
  1. ;; b. ___ Intra-articular fracture (joint fracture) with marked varus or
  1. ;; valgus deformity?
  1. ;; If checked, indicate side: ___ Right ___ Left ___ Both
  1. ;;
  1. ;; c. ___ Intra-articular fracture (joint fracture) with ununited fracture of
  1. ;; the head of the radius?
  1. ;; If checked, indicate side: ___ Right ___ Left ___ Both
  1. ;;^TOF^
  1. ;; d. ___ Impairment of supination or pronation
  1. ;; If checked, indicate severity and side
  1. ;; ___ Supination limited to 30 degrees or less
  1. ;; ___ Right ___ Left ___ Both
  1. ;; ___ Limited pronation with motion lost beyond the last quarter
  1. ;; of the arc; hand does not approach full pronation
  1. ;; ___ Right ___ Left ___ Both
  1. ;; ___ Limited pronation with motion lost beyond the middle of the arc
  1. ;; ___ Right ___ Left ___ Both
  1. ;; ___ Hand is fixed near the middle of the arc or moderate pronation due
  1. ;; to bone fusion
  1. ;; ___ Right ___ Left ___ Both
  1. ;; ___ Hand fixed in full pronation due to bone fusion
  1. ;; ___ Right ___ Left ___ Both
  1. ;; ___ Hand fixed in supination or hyperpronation due to bone fusion
  1. ;; ___ Right ___ Left ___ Both
  1. ;;
  1. ;; 11. Joint replacement and other surgical procedures
  1. ;; a. Has the Veteran had a total elbow joint replacement?
  1. ;; ___ Yes ___ No
  1. ;; If yes, indicate side and severity of residuals.
  1. ;; ___ Right elbow
  1. ;; Date of surgery: ___________________
  1. ;; Residuals:
  1. ;; ___ None
  1. ;; ___ Intermediate degrees of residual weakness, pain and/or
  1. ;; limitation of motion
  1. ;; ___ Chronic residuals consisting of severe painful motion and/or
  1. ;; weakness
  1. ;; ___ Other, describe: _____________
  1. ;; ___ Left elbow
  1. ;; Date of surgery: ___________________
  1. ;; Residuals:
  1. ;; ___ None
  1. ;; ___ Intermediate degrees of residual weakness, pain or limitation
  1. ;; of motion
  1. ;; ___ Chronic residuals consisting of severe painful motion or
  1. ;; weakness
  1. ;; ___ Other, describe: _____________________________________________
  1. ;;
  1. ;; b. Has the Veteran had arthroscopic or other elbow surgery?
  1. ;; ___ Yes ___ No
  1. ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
  1. ;; Date and type of surgery: _____________
  1. ;;
  1. ;; c. Does the Veteran have any residual signs and/or symptoms due to
  1. ;; arthroscopic or other elbow surgery?
  1. ;; ___ Yes ___ No
  1. ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
  1. ;; If yes, describe residuals: _____________________________________________
  1. ;;
  1. Q