DVBCQEL3 ;;ALB-CIOFO/ECF - ELBOW AND FOREARM QUESTIONNAIRE ; 2/15/2011
;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
;
TXT ;
;; 12. 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): ___________________________________________
;;
;; NOTE: In all forearm injuries, if there are impaired finger movements due
;; to tendon, muscle or nerve injuries, also complete the appropriate
;; disability Questionnaire(s), such as the Hand, Peripheral Nerve and/or
;; Muscle Injuries Questionnaire.
;;
;; 13. Remaining effective function of the extremities
;; Due to the service-connected disabling condition(s), is there functional
;; impairment of an extremity such that no effective function remains other
;; than that which would be equally well served by an amputation with
;; prosthesis? (Functions of the upper extremity include grasping,
;; manipulation, etc., while functions for the lower extremity include
;; balance and propulsion, etc.)
;; ___ Yes, functioning is so diminished that amputation with prosthesis
;; would equally serve the Veteran.
;; ___ No
;; If yes, indicate extremities for which this applies:
;; ___ Right upper ___ Left upper
;; For each checked extremity, identify the condition causing loss of
;; function, describe loss of effective function and provide specific
;; examples (brief summary): _______________________________________________
;;^TOF^
;; 14. Diagnostic Testing
;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
;; arthritis must be confirmed by imaging studies. Once such arthritis has
;; been documented, no further imaging studies are required by VA, even if
;; arthritis has worsened.
;;
;; a. Have imaging studies of the elbow been performed and are the results
;; available?
;; ___ Yes ___ No
;; If yes, is degenerative or traumatic arthritis documented?
;; ___ Yes ___ No
;; If yes, indicate elbow: ___ Right ___ Left ___ Both
;;
;; b. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief
;; summary): _______________________________________________________________
;;
;; 15. Functional impact
;; Does the Veteran's elbow/forearm condition impact his or her ability to work?
;; ___ Yes ___ No
;; If yes describe the impact of each of the Veteran's conditions providing one
;; or more examples ____________________________________________________________
;;
;; 16. Remarks, if any: ________________________________________________________
;;
;; Physician signature: _____________________________________ Date: ____________
;;
;; Physician printed name: _____________________________________________________
;;
;; Medical license #: __________________________________________________________
;;
;; Physician address: __________________________________________________________
;;
;; Phone: _____________________________ FAX: _______________________________
;;
;; 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[HDVBCQEL3 4017 printed Sep 23, 2025@19:22:11 Page 2
DVBCQEL3 ;;ALB-CIOFO/ECF - ELBOW AND FOREARM QUESTIONNAIRE ; 2/15/2011
+1 ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; 12. Other pertinent physical findings, complications, conditions, signs
+2 ;; and/or symptoms
+3 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+4 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+5 ;; section above?
+6 ;; ___ Yes ___ No
+7 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+8 ;; of all related scars greater than 39 square cm (6 square inches)?
+9 ;; ___ Yes ___ No
+10 ;; If yes, also complete a Scars Questionnaire.
+11 ;;
+12 ;; b. Does the Veteran have any other pertinent physical findings,
+13 ;; complications, conditions, signs and/or symptoms related to any conditions
+14 ;; listed in the Diagnosis section above?
+15 ;; ___ Yes ___ No
+16 ;; If yes, describe (brief summary): ___________________________________________
+17 ;;
+18 ;; NOTE: In all forearm injuries, if there are impaired finger movements due
+19 ;; to tendon, muscle or nerve injuries, also complete the appropriate
+20 ;; disability Questionnaire(s), such as the Hand, Peripheral Nerve and/or
+21 ;; Muscle Injuries Questionnaire.
+22 ;;
+23 ;; 13. Remaining effective function of the extremities
+24 ;; Due to the service-connected disabling condition(s), is there functional
+25 ;; impairment of an extremity such that no effective function remains other
+26 ;; than that which would be equally well served by an amputation with
+27 ;; prosthesis? (Functions of the upper extremity include grasping,
+28 ;; manipulation, etc., while functions for the lower extremity include
+29 ;; balance and propulsion, etc.)
+30 ;; ___ Yes, functioning is so diminished that amputation with prosthesis
+31 ;; would equally serve the Veteran.
+32 ;; ___ No
+33 ;; If yes, indicate extremities for which this applies:
+34 ;; ___ Right upper ___ Left upper
+35 ;; For each checked extremity, identify the condition causing loss of
+36 ;; function, describe loss of effective function and provide specific
+37 ;; examples (brief summary): _______________________________________________
+38 ;;^TOF^
+39 ;; 14. Diagnostic Testing
+40 ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
+41 ;; arthritis must be confirmed by imaging studies. Once such arthritis has
+42 ;; been documented, no further imaging studies are required by VA, even if
+43 ;; arthritis has worsened.
+44 ;;
+45 ;; a. Have imaging studies of the elbow been performed and are the results
+46 ;; available?
+47 ;; ___ Yes ___ No
+48 ;; If yes, is degenerative or traumatic arthritis documented?
+49 ;; ___ Yes ___ No
+50 ;; If yes, indicate elbow: ___ Right ___ Left ___ Both
+51 ;;
+52 ;; b. Are there any other significant diagnostic test findings and/or results?
+53 ;; ___ Yes ___ No
+54 ;; If yes, provide type of test or procedure, date and results (brief
+55 ;; summary): _______________________________________________________________
+56 ;;
+57 ;; 15. Functional impact
+58 ;; Does the Veteran's elbow/forearm condition impact his or her ability to work?
+59 ;; ___ Yes ___ No
+60 ;; If yes describe the impact of each of the Veteran's conditions providing one
+61 ;; or more examples ____________________________________________________________
+62 ;;
+63 ;; 16. Remarks, if any: ________________________________________________________
+64 ;;
+65 ;; Physician signature: _____________________________________ Date: ____________
+66 ;;
+67 ;; Physician printed name: _____________________________________________________
+68 ;;
+69 ;; Medical license #: __________________________________________________________
+70 ;;
+71 ;; Physician address: __________________________________________________________
+72 ;;
+73 ;; Phone: _____________________________ FAX: _______________________________
+74 ;;
+75 ;; NOTE: VA may request additional medical information, including additional
+76 ;; examinations if necessary to complete VA's review of the Veteran's
+77 ;; application.
+78 ;;^END^
+79 QUIT
