DVBCQFF2 ;;ALB-CIOFO/ECF - FLATFOOT QUESTIONNAIRE ; 6-JUNE-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 flatfoot (pes planus)?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to flatfoot:
;;
;; 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 flatfoot, list using
;; above format: ______________________________________________________________
;;
;; If the Veteran has additional foot conditions other than flatfoot, (such
;; as extreme tenderness on the plantar surfaces of the feet indicating
;; plantar fasciitis), complete the Foot Miscellaneous Questionnaire.
;;
;; 2. Medical history
;; Describe the history (including onset and course) of the Veteran's current
;; flatfoot condition (i.e., when did flatfoot first become symptomatic?)
;; (brief summary): ___________________________________________________________
;;
;; 3. Signs and symptoms
;; Indicate all signs and symptoms that apply to the Veteran's flatfoot
;; condition, regardless of whether similar signs and symptoms appear more
;; than once in different sections.
;;
;; a. Does the Veteran have pain on use of the feet?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; If yes, is the pain accentuated on use?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;;^TOF^
;; b. Does the Veteran have pain on manipulation of the feet?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; If yes, is the pain accentuated on manipulation?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;;
;; c. Is there indication of swelling on use?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;;
;; d. Does the Veteran have characteristic calluses (or any calluses caused
;; by the flatfoot condition)?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;;
;; e. Are the Veteran's symptoms relieved by arch supports (or built up shoes
;; or orthotics)?
;; ___ Yes ___ No
;; If no, indicate side that remains symptomatic despite arch supports or
;; orthotics:
;; ___ Right ___ Left ___ Both
;;
;; f. Does the Veteran have extreme tenderness of plantar surface of one or
;; both feet?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; Is the tenderness improved by orthopedic shoes or appliances?
;; ___ Yes ___ No
;;
;; 4. Alignment and deformity
;; a. Does the Veteran have decreased longitudinal arch height on
;; weight-bearing?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;;
;; b. Is there objective evidence of marked deformity of the foot (pronation,
;; abduction etc.)?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;;
;; c. Is there marked pronation of the foot?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; If yes, is the condition improved by orthopedic shoes or appliances?
;; ___ Yes ___ No
;;
;; d. Does the weight-bearing line fall over or medial to the great toe?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;;^TOF^
;; e. Is there a lower extremity deformity other than pes planus, causing
;; alteration of the weight bearing line?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; Describe lower extremity deformity other than pes planus causing alteration
;; of the weight bearing line: ____________
;;
;; f. Does the Veteran have "inward" bowing of the Achilles' tendon (i.e.,
;; hind foot valgus, with lateral deviation of the heel)?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;;
;; g. Does the Veteran have marked inward displacement and severe spasm of the
;; Achilles tendon (rigid hindfoot) on manipulation?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; Is the marked inward displacement and severe spasm of the Achilles tendon
;; improved by orthopedic shoes or appliances?
;; ___ Yes ___ No
;; If yes, indicate side improved by orthopedic shoes or appliances:
;; ___ Right ___ Left ___ Both
;;
;; 5. 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): __________________________________________
;;^TOF^
;; 6. Assistive devices
;; a. Does the Veteran use any assistive devices (other than corrective
;; shoes or orthotic inserts) as a normal mode of locomotion, although
;; occasional locomotion by other methods may be possible?
;; ___ Yes ___ No
;; If yes, identify assistive devices used (check all that apply and indicate
;; frequency):
;;
;; ___ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
;; ___ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
;; ___ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
;; ___ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
;; ___ Walker Frequency of use: __ Occasional __ Regular __ Constant
;; ___ Other: _____________________
;; Frequency of use: __ Occasional __ Regular __ Constant
;;
;; b. If the Veteran uses any assistive devices, specify the condition and
;; identify the assistive device used for each condition: _____________________
;; ____________________________________________________________________________
;;
;; 7. Remaining effective function of the extremities
;; Due to the Veteran's flatfoot condition, 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 lower ___ Left lower
;; Identify the condition causing loss of function, describe loss of effective
;; function and provide specific examples (brief summary): ____________________
;;
;; 8. Diagnostic Testing
;; NOTE: Plain or weight-bearing foot x-rays are not required to make the
;; diagnosis of flatfoot. 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 foot been performed and are the results
;; available?
;; ___ Yes ___ No
;; If yes, is degenerative or traumatic arthritis documented?
;; ___ Yes ___ No
;; If yes, indicate foot: ___ Right ___ Left ___ Both
;;
;; b. Are there any other significant diagnostic test finding and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;
;; 9. Functional impact
;; Does the Veteran's flatfoot condition impact his or her ability to work?
;; ___ Yes ___ No
;; If yes describe the impact of each of the Veteran's flatfoot conditions
;; providing one or more examples: ____
;;
;; 10. 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[HDVBCQFF2 10217 printed Apr 09, 2024@20:52:18 Page 2
DVBCQFF2 ;;ALB-CIOFO/ECF - FLATFOOT QUESTIONNAIRE ; 6-JUNE-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 flatfoot (pes planus)?
+7 ;; ___ Yes ___ No
+8 ;;
+9 ;; If yes, provide only diagnoses that pertain to flatfoot:
+10 ;;
+11 ;; Diagnosis #1: ___________________________
+12 ;; ICD code: ______________________________
+13 ;; Date of diagnosis: ______________________
+14 ;; Side affected: ___ Right ___ Left ___ Both
+15 ;;
+16 ;; Diagnosis #2: ___________________________
+17 ;; ICD code: ______________________________
+18 ;; Date of diagnosis: ______________________
+19 ;; Side affected: ___ Right ___ Left ___ Both
+20 ;;
+21 ;; Diagnosis #3: ____________________________
+22 ;; ICD code: _______________________________
+23 ;; Date of diagnosis: _______________________
+24 ;; Side affected: ___ Right ___ Left ___ Both
+25 ;;
+26 ;; If there are additional diagnoses that pertain to flatfoot, list using
+27 ;; above format: ______________________________________________________________
+28 ;;
+29 ;; If the Veteran has additional foot conditions other than flatfoot, (such
+30 ;; as extreme tenderness on the plantar surfaces of the feet indicating
+31 ;; plantar fasciitis), complete the Foot Miscellaneous Questionnaire.
+32 ;;
+33 ;; 2. Medical history
+34 ;; Describe the history (including onset and course) of the Veteran's current
+35 ;; flatfoot condition (i.e., when did flatfoot first become symptomatic?)
+36 ;; (brief summary): ___________________________________________________________
+37 ;;
+38 ;; 3. Signs and symptoms
+39 ;; Indicate all signs and symptoms that apply to the Veteran's flatfoot
+40 ;; condition, regardless of whether similar signs and symptoms appear more
+41 ;; than once in different sections.
+42 ;;
+43 ;; a. Does the Veteran have pain on use of the feet?
+44 ;; ___ Yes ___ No
+45 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+46 ;; If yes, is the pain accentuated on use?
+47 ;; ___ Yes ___ No
+48 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+49 ;;^TOF^
+50 ;; b. Does the Veteran have pain on manipulation of the feet?
+51 ;; ___ Yes ___ No
+52 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+53 ;; If yes, is the pain accentuated on manipulation?
+54 ;; ___ Yes ___ No
+55 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+56 ;;
+57 ;; c. Is there indication of swelling on use?
+58 ;; ___ Yes ___ No
+59 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+60 ;;
+61 ;; d. Does the Veteran have characteristic calluses (or any calluses caused
+62 ;; by the flatfoot condition)?
+63 ;; ___ Yes ___ No
+64 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+65 ;;
+66 ;; e. Are the Veteran's symptoms relieved by arch supports (or built up shoes
+67 ;; or orthotics)?
+68 ;; ___ Yes ___ No
+69 ;; If no, indicate side that remains symptomatic despite arch supports or
+70 ;; orthotics:
+71 ;; ___ Right ___ Left ___ Both
+72 ;;
+73 ;; f. Does the Veteran have extreme tenderness of plantar surface of one or
+74 ;; both feet?
+75 ;; ___ Yes ___ No
+76 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+77 ;; Is the tenderness improved by orthopedic shoes or appliances?
+78 ;; ___ Yes ___ No
+79 ;;
+80 ;; 4. Alignment and deformity
+81 ;; a. Does the Veteran have decreased longitudinal arch height on
+82 ;; weight-bearing?
+83 ;; ___ Yes ___ No
+84 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+85 ;;
+86 ;; b. Is there objective evidence of marked deformity of the foot (pronation,
+87 ;; abduction etc.)?
+88 ;; ___ Yes ___ No
+89 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+90 ;;
+91 ;; c. Is there marked pronation of the foot?
+92 ;; ___ Yes ___ No
+93 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+94 ;; If yes, is the condition improved by orthopedic shoes or appliances?
+95 ;; ___ Yes ___ No
+96 ;;
+97 ;; d. Does the weight-bearing line fall over or medial to the great toe?
+98 ;; ___ Yes ___ No
+99 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+100 ;;^TOF^
+101 ;; e. Is there a lower extremity deformity other than pes planus, causing
+102 ;; alteration of the weight bearing line?
+103 ;; ___ Yes ___ No
+104 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+105 ;; Describe lower extremity deformity other than pes planus causing alteration
+106 ;; of the weight bearing line: ____________
+107 ;;
+108 ;; f. Does the Veteran have "inward" bowing of the Achilles' tendon (i.e.,
+109 ;; hind foot valgus, with lateral deviation of the heel)?
+110 ;; ___ Yes ___ No
+111 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+112 ;;
+113 ;; g. Does the Veteran have marked inward displacement and severe spasm of the
+114 ;; Achilles tendon (rigid hindfoot) on manipulation?
+115 ;; ___ Yes ___ No
+116 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+117 ;; Is the marked inward displacement and severe spasm of the Achilles tendon
+118 ;; improved by orthopedic shoes or appliances?
+119 ;; ___ Yes ___ No
+120 ;; If yes, indicate side improved by orthopedic shoes or appliances:
+121 ;; ___ Right ___ Left ___ Both
+122 ;;
+123 ;; 5. Other pertinent physical findings, complications, conditions, signs
+124 ;; and/or symptoms
+125 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+126 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+127 ;; section above?
+128 ;; ___ Yes ___ No
+129 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+130 ;; of all related scars greater than 39 square cm (6 square inches)?
+131 ;; ___ Yes ___ No
+132 ;; If yes, also complete a Scars Questionnaire.
+133 ;;
+134 ;; b. Does the Veteran have any other pertinent physical findings,
+135 ;; complications, conditions, signs and/or symptoms related to any
+136 ;; conditions listed in the Diagnosis section above?
+137 ;; ___ Yes ___ No
+138 ;; If yes, describe (brief summary): __________________________________________
+139 ;;^TOF^
+140 ;; 6. Assistive devices
+141 ;; a. Does the Veteran use any assistive devices (other than corrective
+142 ;; shoes or orthotic inserts) as a normal mode of locomotion, although
+143 ;; occasional locomotion by other methods may be possible?
+144 ;; ___ Yes ___ No
+145 ;; If yes, identify assistive devices used (check all that apply and indicate
+146 ;; frequency):
+147 ;;
+148 ;; ___ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
+149 ;; ___ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
+150 ;; ___ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
+151 ;; ___ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
+152 ;; ___ Walker Frequency of use: __ Occasional __ Regular __ Constant
+153 ;; ___ Other: _____________________
+154 ;; Frequency of use: __ Occasional __ Regular __ Constant
+155 ;;
+156 ;; b. If the Veteran uses any assistive devices, specify the condition and
+157 ;; identify the assistive device used for each condition: _____________________
+158 ;; ____________________________________________________________________________
+159 ;;
+160 ;; 7. Remaining effective function of the extremities
+161 ;; Due to the Veteran's flatfoot condition, is there functional impairment of
+162 ;; an extremity such that no effective function remains other than that which
+163 ;; would be equally well served by an amputation with prosthesis? (Functions
+164 ;; of the upper extremity include grasping, manipulation, etc., while
+165 ;; functions for the lower extremity include balance and propulsion, etc.)
+166 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+167 ;; equally serve the Veteran.
+168 ;; ___ No
+169 ;; If yes, indicate extremities for which this applies:
+170 ;; ___ Right lower ___ Left lower
+171 ;; Identify the condition causing loss of function, describe loss of effective
+172 ;; function and provide specific examples (brief summary): ____________________
+173 ;;
+174 ;; 8. Diagnostic Testing
+175 ;; NOTE: Plain or weight-bearing foot x-rays are not required to make the
+176 ;; diagnosis of flatfoot. The diagnosis of degenerative arthritis
+177 ;; (osteoarthritis) or traumatic arthritis must be confirmed by imaging
+178 ;; studies. Once such arthritis has been documented, no further imaging
+179 ;; studies are required by VA, even if arthritis has worsened.
+180 ;;
+181 ;; a. Have imaging studies of the foot been performed and are the results
+182 ;; available?
+183 ;; ___ Yes ___ No
+184 ;; If yes, is degenerative or traumatic arthritis documented?
+185 ;; ___ Yes ___ No
+186 ;; If yes, indicate foot: ___ Right ___ Left ___ Both
+187 ;;
+188 ;; b. Are there any other significant diagnostic test finding and/or results?
+189 ;; ___ Yes ___ No
+190 ;; If yes, provide type of test or procedure, date and results (brief summary):
+191 ;; ____________________________________________________________________________
+192 ;;
+193 ;; 9. Functional impact
+194 ;; Does the Veteran's flatfoot condition impact his or her ability to work?
+195 ;; ___ Yes ___ No
+196 ;; If yes describe the impact of each of the Veteran's flatfoot conditions
+197 ;; providing one or more examples: ____
+198 ;;
+199 ;; 10. Remarks, if any: _______________________________________________________
+200 ;;
+201 ;; Physician signature: _____________________________________ Date: ___________
+202 ;;
+203 ;; Physician printed name: ____________________________________________________
+204 ;;
+205 ;; Medical license #: _________________________________________________________
+206 ;;
+207 ;; Physician address: _________________________________________________________
+208 ;;
+209 ;; Phone: _____________________________ FAX: ______________________________
+210 ;;
+211 ;; NOTE: VA may request additional medical information, including additional
+212 ;; examinations if necessary to complete VA's review of the Veteran's
+213 ;; application.
+214 ;;^END^
+215 QUIT
