©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
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^
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