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Routine: DVBCQEL3

DVBCQEL3.m

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  1. DVBCQEL3 ;;ALB-CIOFO/ECF - ELBOW AND FOREARM QUESTIONNAIRE ; 2/15/2011
  1.  ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; 12. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, are any of the scars painful and/or unstable, or is the total area
  1.  ;; of all related scars greater than 39 square cm (6 square inches)?
  1.  ;;    ___ Yes   ___ No
  1.  ;;        If yes, also complete a Scars Questionnaire.
  1.  ;;
  1.  ;; b.  Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs and/or symptoms related to any conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): ___________________________________________
  1.  ;;
  1.  ;; NOTE: In all forearm injuries, if there are impaired finger movements due
  1.  ;; to tendon, muscle or nerve injuries, also complete the appropriate
  1.  ;; disability Questionnaire(s), such as the Hand, Peripheral Nerve and/or
  1.  ;; Muscle Injuries Questionnaire.
  1.  ;;
  1.  ;; 13. Remaining effective function of the extremities
  1.  ;; Due to the service-connected disabling condition(s), is there functional
  1.  ;; impairment of an extremity such that no effective function remains other
  1.  ;; than that which would be equally well served by an amputation with
  1.  ;; prosthesis? (Functions of the upper extremity include grasping,
  1.  ;; manipulation, etc., while functions for the lower extremity include
  1.  ;; balance and propulsion, etc.)
  1.  ;; ___ Yes, functioning is so diminished that amputation with prosthesis
  1.  ;;     would equally serve the Veteran.
  1.  ;; ___ No
  1.  ;;     If yes, indicate extremities for which this applies:
  1.  ;;     ___ Right upper    ___ Left upper
  1.  ;;     For each checked extremity, identify the condition causing loss of
  1.  ;;     function, describe loss of effective function and provide specific
  1.  ;;     examples (brief summary): _______________________________________________
  1.  ;;^TOF^
  1.  ;; 14.  Diagnostic Testing
  1.  ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
  1.  ;; arthritis must be confirmed by imaging studies. Once such arthritis has
  1.  ;; been documented, no further imaging studies are required by VA, even if
  1.  ;; arthritis has worsened.
  1.  ;;
  1.  ;; a. Have imaging studies of the elbow been performed and are the results
  1.  ;; available?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, is degenerative or traumatic arthritis documented?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If yes, indicate elbow: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If yes, provide type of test or procedure, date and results (brief
  1.  ;;     summary): _______________________________________________________________
  1.  ;;
  1.  ;; 15. Functional impact
  1.  ;; Does the Veteran's elbow/forearm condition impact his or her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes describe the impact of each of the Veteran's conditions providing one
  1.  ;; or more examples ____________________________________________________________
  1.  ;;
  1.  ;; 16. Remarks, if any: ________________________________________________________
  1.  ;;
  1.  ;; Physician signature: _____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: _____________________________________________________
  1.  ;;
  1.  ;; Medical license #: __________________________________________________________
  1.  ;;
  1.  ;; Physician address: __________________________________________________________
  1.  ;;
  1.  ;; Phone: _____________________________     FAX: _______________________________
  1.  ;;
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's
  1.  ;; application.
  1.  ;;^END^
  1.  Q