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Routine: DVBCQFF2

DVBCQFF2.m

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  1. DVBCQFF2 ;;ALB-CIOFO/ECF - FLATFOOT QUESTIONNAIRE ; 6-JUNE-2011
  1.  ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1.  ;; disability benefits.  VA will consider the information you provide on this
  1.  ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;; Does the Veteran now have or has he/she ever had flatfoot (pes planus)?
  1.  ;; ___ Yes  ___ No
  1.  ;;
  1.  ;; If yes, provide only diagnoses that pertain to flatfoot:
  1.  ;;
  1.  ;; Diagnosis #1: ___________________________
  1.  ;; ICD code:  ______________________________
  1.  ;; Date of diagnosis: ______________________
  1.  ;; Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; Diagnosis #2: ___________________________
  1.  ;; ICD code:  ______________________________
  1.  ;; Date of diagnosis: ______________________
  1.  ;; Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; Diagnosis #3: ____________________________
  1.  ;; ICD code:  _______________________________
  1.  ;; Date of diagnosis: _______________________
  1.  ;; Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to flatfoot, list using
  1.  ;; above format: ______________________________________________________________
  1.  ;;
  1.  ;; If the Veteran has additional foot conditions other than flatfoot, (such
  1.  ;; as extreme tenderness on the plantar surfaces of the feet indicating
  1.  ;; plantar fasciitis), complete the Foot Miscellaneous Questionnaire.
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;; Describe the history (including onset and course) of the Veteran's current
  1.  ;; flatfoot condition (i.e., when did flatfoot first become symptomatic?)
  1.  ;; (brief summary): ___________________________________________________________ 
  1.  ;;
  1.  ;; 3. Signs and symptoms 
  1.  ;; Indicate all signs and symptoms that apply to the Veteran's flatfoot
  1.  ;; condition, regardless of whether similar signs and symptoms appear more
  1.  ;; than once in different sections.
  1.  ;;
  1.  ;; a. Does the Veteran have pain on use of the feet?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;; If yes, is the pain accentuated on use?
  1.  ;;    ___ Yes   ___ No   
  1.  ;;    If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;^TOF^
  1.  ;; b. Does the Veteran have pain on manipulation of the feet?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;; If yes, is the pain accentuated on manipulation?
  1.  ;;    ___ Yes   ___ No   
  1.  ;;    If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; c. Is there indication of swelling on use?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; d. Does the Veteran have characteristic calluses (or any calluses caused
  1.  ;; by the flatfoot condition)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; e. Are the Veteran's symptoms relieved by arch supports (or built up shoes
  1.  ;; or orthotics)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If no, indicate side that remains symptomatic despite arch supports or
  1.  ;; orthotics: 
  1.  ;; ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; f. Does the Veteran have extreme tenderness of plantar surface of one or
  1.  ;; both feet?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;    Is the tenderness improved by orthopedic shoes or appliances?
  1.  ;;    ___ Yes   ___ No
  1.  ;;
  1.  ;; 4. Alignment and deformity
  1.  ;; a. Does the Veteran have decreased longitudinal arch height on
  1.  ;; weight-bearing?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Is there objective evidence of marked deformity of the foot (pronation,
  1.  ;; abduction etc.)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; c. Is there marked pronation of the foot? 
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;; If yes, is the condition improved by orthopedic shoes or appliances?
  1.  ;; ___ Yes   ___ No  
  1.  ;;
  1.  ;; d. Does the weight-bearing line fall over or medial to the great toe?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;^TOF^
  1.  ;; e. Is there a lower extremity deformity other than pes planus, causing
  1.  ;; alteration of the weight bearing line?
  1.  ;; ___ Yes   ___ No   
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;; Describe lower extremity deformity other than pes planus causing alteration
  1.  ;; of the weight bearing line: ____________
  1.  ;;
  1.  ;; f. Does the Veteran have "inward" bowing of the Achilles' tendon (i.e.,
  1.  ;; hind foot valgus, with lateral deviation of the heel)? 
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;; 
  1.  ;; g. Does the Veteran have marked inward displacement and severe spasm of the
  1.  ;; Achilles tendon (rigid hindfoot) on manipulation?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;    Is the marked inward displacement and severe spasm of the Achilles tendon
  1.  ;;    improved by orthopedic shoes or appliances?
  1.  ;;     ___ Yes   ___ No
  1.  ;;     If yes, indicate side improved by orthopedic shoes or appliances:
  1.  ;;     ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; 5. 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
  1.  ;; conditions listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No  
  1.  ;; If yes, describe (brief summary): __________________________________________
  1.  ;;^TOF^
  1.  ;; 6. Assistive devices
  1.  ;; a. Does the Veteran use any assistive devices (other than corrective
  1.  ;; shoes or orthotic inserts) as a normal mode of locomotion, although
  1.  ;; occasional locomotion by other methods may be possible? 
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, identify assistive devices used (check all that apply and indicate
  1.  ;; frequency):
  1.  ;;
  1.  ;;   ___ Wheelchair  Frequency of use: __ Occasional   __ Regular   __ Constant
  1.  ;;   ___ Brace(s)    Frequency of use: __ Occasional   __ Regular   __ Constant
  1.  ;;   ___ Crutch(es)  Frequency of use: __ Occasional   __ Regular   __ Constant
  1.  ;;   ___ Cane(s)     Frequency of use: __ Occasional   __ Regular   __ Constant
  1.  ;;   ___ Walker      Frequency of use: __ Occasional   __ Regular   __ Constant
  1.  ;;   ___ Other: _____________________
  1.  ;;                   Frequency of use: __ Occasional   __ Regular   __ Constant
  1.  ;;
  1.  ;; b. If the Veteran uses any assistive devices, specify the condition and
  1.  ;; identify the assistive device used for each condition: _____________________
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 7. Remaining effective function of the extremities
  1.  ;; Due to the Veteran's flatfoot condition, is there functional impairment of
  1.  ;; an extremity such that no effective function remains other than that which
  1.  ;; would be equally well served by an amputation with prosthesis? (Functions
  1.  ;; of the upper extremity include grasping, manipulation, etc., while
  1.  ;; functions for the lower extremity include balance and propulsion, etc.)
  1.  ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
  1.  ;; equally serve the Veteran. 
  1.  ;; ___ No
  1.  ;; If yes, indicate extremities for which this applies:  
  1.  ;;     ___ Right lower   ___ Left lower
  1.  ;; Identify the condition causing loss of function, describe loss of effective
  1.  ;; function and provide specific examples (brief summary): ____________________ 
  1.  ;; 
  1.  ;; 8.  Diagnostic Testing
  1.  ;; NOTE: Plain or weight-bearing foot x-rays are not required to make the
  1.  ;; diagnosis of flatfoot. The diagnosis of degenerative arthritis
  1.  ;; (osteoarthritis) or traumatic arthritis must be confirmed by imaging
  1.  ;; studies. Once such arthritis has been documented, no further imaging
  1.  ;; studies are required by VA, even if arthritis has worsened. 
  1.  ;;
  1.  ;; a. Have imaging studies of the foot 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 foot: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Are there any other significant diagnostic test finding and/or results?
  1.  ;; ___ Yes   ___ No  
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 9. Functional impact
  1.  ;; Does the Veteran's flatfoot condition impact his or her ability to work? 
  1.  ;; ___ Yes   ___ No 
  1.  ;; If yes describe the impact of each of the Veteran's flatfoot conditions
  1.  ;; providing one or more examples: ____
  1.  ;;
  1.  ;; 10. 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