- 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 Feb 18, 2025@23:12:33 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