DVBCQFM2 ;;ALB-CIOFO/ECF - FOOT MISCELLANEOUS QUESTIONNAIRE ; 20/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 a foot condition (other
;; than flatfoot)?
;; ___ Yes ___ No
;;
;; If yes, indicate diagnosis/es: (check all that apply) and complete
;; appropriate section(s).
;; Provide only diagnoses that pertain to foot conditions other than flatfoot:
;; ___ Morton's neuroma ICD code: ______ Date of diagnosis: ___________
;; ___ Metatarsalgia ICD code: ______ Date of diagnosis: ___________
;; ___ Hammer toes ICD code: ______ Date of diagnosis: ___________
;; ___ Hallux valgus ICD code: ______ Date of diagnosis: ___________
;; ___ Hallux rigidus ICD code: ______ Date of diagnosis: ___________
;; ___ Claw foot (pes cavus) ICD code: ______ Date of diagnosis: ___________
;; ___ Malunion/nonunion of tarsal/metatarsal bones
;; ICD code: ______ Date of diagnosis: ___________
;; ___ Foot injuries (specify): ____________
;; ICD code: ______ Date of diagnosis: ___________
;; ___ Other foot conditions (specify): _____
;; ICD code: ______ Date of diagnosis: ___________
;;
;; NOTE: If the Veteran has flatfoot, also complete the Flatfoot Questionnaire.
;;
;; 2. Medical history
;; Describe the history (including onset and course) of the Veteran's current
;; foot condition (brief summary): ____________________________________________
;;
;; 3. Morton's neuroma (Morton's disease) and metatarsalgia
;; a. Does the Veteran have Morton's neuroma?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;;
;; b. Does the Veteran have metatarsalgia?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;;
;; 4. Hammer toe
;; Does the Veteran have hammer toes?
;; ___ Yes ___ No
;; If yes, which toes are affected on each side?
;; Right:
;; ___ None ___ Great toe ___ Second toe
;; ___ Third toe ___ Fourth toe ___ Little toe
;; Left:
;; ___ None ___ Great toe ___ Second toe
;; ___ Third toe ___ Fourth toe ___ Little toe
;;
;; 5. Hallux valgus
;; Does the Veteran now have or has he/she ever had hallux valgus?
;; ___ Yes ___ No
;; If yes, complete the following:
;;
;; a. Does the Veteran have symptoms due to a hallux valgus condition?
;; ___ Yes ___ No
;; If yes, indicate severity (check all that apply):
;; ___ Mild or moderate symptoms
;; Side affected: ___ Right ___ Left ___ Both
;; ___ Severe symptoms, with function equivalent to amputation of great toe
;; Side affected: ___ Right ___ Left ___ Both
;;
;; b. Has the Veteran had surgery for hallux valgus?
;; ___ Yes ___ No
;; If yes, indicate type of surgery and side affected:
;; ___ Resection of metatarsal head
;; Date of surgery: ________________
;; Side affected: ___ Right ___ Left ___ Both
;; ___ Metatarsal osteotomy/metatarsal head osteotomy (equivalent to
;; metatarsal head resection)
;; Date of surgery: ________________
;; Side affected: ___ Right ___ Left ___ Both
;; ___ Other surgery for hallux valgus, describe: _________
;; Date of surgery: ________________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; 6. Hallux rigidus
;; Does the Veteran have hallux rigidus?
;; ___ Yes ___ No
;; If yes, does the Veteran have symptoms due to hallux rigidus?
;; ___ Yes ___ No
;; If yes, indicate severity (check all that apply):
;; ___ Mild or moderate symptoms
;; Side affected: ___ Right ___ Left ___ Both
;; ___ Severe symptoms, with function equivalent to amputation of great toe
;; Side affected: ___ Right ___ Left ___ Both
;;
;; 7. Pes cavus (claw foot)
;; Does the Veteran have acquired claw foot (pes cavus)?
;; ___ Yes ___ No
;; If yes, complete the following:
;;
;; a. Effect on toes due to pes cavus (check all that apply)
;; ___ None ___ Right ___ Left ___ Both
;; ___ Great toe dorsiflexed ___ Right ___ Left ___ Both
;; ___ All toes tending to dorsiflexion ___ Right ___ Left ___ Both
;; ___ All toes hammer toes ___ Right ___ Left ___ Both
;; ___ Other, describe (if there is an effect on toes due to other etiology
;; than pes cavus, indicate other etiology): ___________________________
;;
;; b. Pain and tenderness due to pes cavus (check all that apply)
;; ___ None ___ Right ___ Left ___ Both
;; ___ Definite tenderness under metatarsal heads
;; ___ Right ___ Left ___ Both
;; ___ Marked tenderness under metatarsal heads
;; ___ Right ___ Left ___ Both
;; ___ Very painful callosities ___ Right ___ Left ___ Both
;; ___ Other, describe (if the Veteran has pain and tenderness due to other
;; etiology than pes cavus, indicate other etiology): ___________________
;;
;; c. Effect on plantar fascia due to pes cavus (check all that apply)
;; ___ None ___ Right ___ Left ___ Both
;; ___ Shortened plantar fascia ___ Right ___ Left ___ Both
;; ___ Marked contraction of plantar fascia with
;; dropped forefoot ___ Right ___ Left ___ Both
;; ___ Other, describe (if there is an effect on plantar fascia due to other
;; etiology than pes cavus, indicate other etiology): ___________________
;;
;; d. Dorsiflexion and varus deformity due to pes cavus (check all that apply)
;; ___ None ___ Right ___ Left ___ Both
;; ___ Some limitation of dorsiflexion at ankle
;; ___ Right ___ Left ___ Both
;; ___ Limitation of dorsiflexion at ankle to right angle
;; ___ Right ___ Left ___ Both
;; ___ Marked varus deformity ___ Right ___ Left ___ Both
;; ___ Other, describe (if the Veteran has dorsiflexion and varus deformity
;; due to other etiology than pes cavus, indicate other etiology): ______
;; ______________________________________________________________________
;;
;; 8. Malunion or nonunion of tarsal or metatarsal bones
;; Does the Veteran have malunion or nonunion of tarsal or metatarsal bones?
;; ___ Yes ___ No
;; Indicate severity and side affected:
;; ___ Moderate ___ Right ___ Left ___ Both
;; ___ Moderately severe ___ Right ___ Left ___ Both
;; ___ Severe ___ Right ___ Left ___ Both
;;
;; 9. Foot injuries
;; Does the Veteran have any other foot injuries?
;; ___ Yes ___ No
;; If yes, describe: __________________________________________________________
;; If yes, indicate severity and side affected:
;; ___ Moderate ___ Right ___ Left ___ Both
;; ___ Moderately severe ___ Right ___ Left ___ Both
;; ___ Severe ___ Right ___ Left ___ Both
;;^TOF^
;; 10. Bilateral weak foot
;; NOTE: For VA purposes, bilateral weak foot is a symptomatic condition
;; secondary to many constitutional conditions characterized by atrophy of
;; the musculature, disturbed circulation and weakness.
;;
;; Is there evidence of bilateral weak foot?
;; ___ Yes ___ No
;; If yes, describe and report underlying condition: __________________________
;;
;; 11. 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): __________________________________________
;;
;; 12. Assistive devices
;; a. Does the Veteran use any assistive devices 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: ______________________
;;
;; ____________________________________________________________________________
;;^TOF^
;; 13. Remaining effective function of the extremities
;; Due to the Veteran's foot 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
;;
;; For each checked extremity, describe loss of effective function, identify
;; the condition causing loss of function, and provide specific examples
;; (brief summary): ___________________________________________________________
;;
;; 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 foot been performed and are the results
;; available?
;; ___ Yes ___ No
;; If yes, are there abnormal findings?
;; ___ Yes ___ No
;; If yes, indicate findings:
;; ___ Degenerative or traumatic arthritis
;; Foot: ___ Right ___ Left ___ Both
;; Is degenerative or traumatic arthritis documented in multiple
;; joints of the same foot?
;; ___ Yes ___ No
;; If yes, indicate: ___ Right ___ Left ___ Both
;; ___ Other. Describe: ________________________________________________
;; Foot: ___ 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):
;; ________________________________________________________________________
;;^TOF^
;; 15. Functional impact
;; Does the Veteran's foot condition impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's foot 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[HDVBCQFM2 13394 printed Apr 09, 2024@20:58:01 Page 2
DVBCQFM2 ;;ALB-CIOFO/ECF - FOOT MISCELLANEOUS QUESTIONNAIRE ; 20/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 a foot condition (other
+7 ;; than flatfoot)?
+8 ;; ___ Yes ___ No
+9 ;;
+10 ;; If yes, indicate diagnosis/es: (check all that apply) and complete
+11 ;; appropriate section(s).
+12 ;; Provide only diagnoses that pertain to foot conditions other than flatfoot:
+13 ;; ___ Morton's neuroma ICD code: ______ Date of diagnosis: ___________
+14 ;; ___ Metatarsalgia ICD code: ______ Date of diagnosis: ___________
+15 ;; ___ Hammer toes ICD code: ______ Date of diagnosis: ___________
+16 ;; ___ Hallux valgus ICD code: ______ Date of diagnosis: ___________
+17 ;; ___ Hallux rigidus ICD code: ______ Date of diagnosis: ___________
+18 ;; ___ Claw foot (pes cavus) ICD code: ______ Date of diagnosis: ___________
+19 ;; ___ Malunion/nonunion of tarsal/metatarsal bones
+20 ;; ICD code: ______ Date of diagnosis: ___________
+21 ;; ___ Foot injuries (specify): ____________
+22 ;; ICD code: ______ Date of diagnosis: ___________
+23 ;; ___ Other foot conditions (specify): _____
+24 ;; ICD code: ______ Date of diagnosis: ___________
+25 ;;
+26 ;; NOTE: If the Veteran has flatfoot, also complete the Flatfoot Questionnaire.
+27 ;;
+28 ;; 2. Medical history
+29 ;; Describe the history (including onset and course) of the Veteran's current
+30 ;; foot condition (brief summary): ____________________________________________
+31 ;;
+32 ;; 3. Morton's neuroma (Morton's disease) and metatarsalgia
+33 ;; a. Does the Veteran have Morton's neuroma?
+34 ;; ___ Yes ___ No
+35 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+36 ;;
+37 ;; b. Does the Veteran have metatarsalgia?
+38 ;; ___ Yes ___ No
+39 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+40 ;;
+41 ;; 4. Hammer toe
+42 ;; Does the Veteran have hammer toes?
+43 ;; ___ Yes ___ No
+44 ;; If yes, which toes are affected on each side?
+45 ;; Right:
+46 ;; ___ None ___ Great toe ___ Second toe
+47 ;; ___ Third toe ___ Fourth toe ___ Little toe
+48 ;; Left:
+49 ;; ___ None ___ Great toe ___ Second toe
+50 ;; ___ Third toe ___ Fourth toe ___ Little toe
+51 ;;
+52 ;; 5. Hallux valgus
+53 ;; Does the Veteran now have or has he/she ever had hallux valgus?
+54 ;; ___ Yes ___ No
+55 ;; If yes, complete the following:
+56 ;;
+57 ;; a. Does the Veteran have symptoms due to a hallux valgus condition?
+58 ;; ___ Yes ___ No
+59 ;; If yes, indicate severity (check all that apply):
+60 ;; ___ Mild or moderate symptoms
+61 ;; Side affected: ___ Right ___ Left ___ Both
+62 ;; ___ Severe symptoms, with function equivalent to amputation of great toe
+63 ;; Side affected: ___ Right ___ Left ___ Both
+64 ;;
+65 ;; b. Has the Veteran had surgery for hallux valgus?
+66 ;; ___ Yes ___ No
+67 ;; If yes, indicate type of surgery and side affected:
+68 ;; ___ Resection of metatarsal head
+69 ;; Date of surgery: ________________
+70 ;; Side affected: ___ Right ___ Left ___ Both
+71 ;; ___ Metatarsal osteotomy/metatarsal head osteotomy (equivalent to
+72 ;; metatarsal head resection)
+73 ;; Date of surgery: ________________
+74 ;; Side affected: ___ Right ___ Left ___ Both
+75 ;; ___ Other surgery for hallux valgus, describe: _________
+76 ;; Date of surgery: ________________
+77 ;; Side affected: ___ Right ___ Left ___ Both
+78 ;;
+79 ;; 6. Hallux rigidus
+80 ;; Does the Veteran have hallux rigidus?
+81 ;; ___ Yes ___ No
+82 ;; If yes, does the Veteran have symptoms due to hallux rigidus?
+83 ;; ___ Yes ___ No
+84 ;; If yes, indicate severity (check all that apply):
+85 ;; ___ Mild or moderate symptoms
+86 ;; Side affected: ___ Right ___ Left ___ Both
+87 ;; ___ Severe symptoms, with function equivalent to amputation of great toe
+88 ;; Side affected: ___ Right ___ Left ___ Both
+89 ;;
+90 ;; 7. Pes cavus (claw foot)
+91 ;; Does the Veteran have acquired claw foot (pes cavus)?
+92 ;; ___ Yes ___ No
+93 ;; If yes, complete the following:
+94 ;;
+95 ;; a. Effect on toes due to pes cavus (check all that apply)
+96 ;; ___ None ___ Right ___ Left ___ Both
+97 ;; ___ Great toe dorsiflexed ___ Right ___ Left ___ Both
+98 ;; ___ All toes tending to dorsiflexion ___ Right ___ Left ___ Both
+99 ;; ___ All toes hammer toes ___ Right ___ Left ___ Both
+100 ;; ___ Other, describe (if there is an effect on toes due to other etiology
+101 ;; than pes cavus, indicate other etiology): ___________________________
+102 ;;
+103 ;; b. Pain and tenderness due to pes cavus (check all that apply)
+104 ;; ___ None ___ Right ___ Left ___ Both
+105 ;; ___ Definite tenderness under metatarsal heads
+106 ;; ___ Right ___ Left ___ Both
+107 ;; ___ Marked tenderness under metatarsal heads
+108 ;; ___ Right ___ Left ___ Both
+109 ;; ___ Very painful callosities ___ Right ___ Left ___ Both
+110 ;; ___ Other, describe (if the Veteran has pain and tenderness due to other
+111 ;; etiology than pes cavus, indicate other etiology): ___________________
+112 ;;
+113 ;; c. Effect on plantar fascia due to pes cavus (check all that apply)
+114 ;; ___ None ___ Right ___ Left ___ Both
+115 ;; ___ Shortened plantar fascia ___ Right ___ Left ___ Both
+116 ;; ___ Marked contraction of plantar fascia with
+117 ;; dropped forefoot ___ Right ___ Left ___ Both
+118 ;; ___ Other, describe (if there is an effect on plantar fascia due to other
+119 ;; etiology than pes cavus, indicate other etiology): ___________________
+120 ;;
+121 ;; d. Dorsiflexion and varus deformity due to pes cavus (check all that apply)
+122 ;; ___ None ___ Right ___ Left ___ Both
+123 ;; ___ Some limitation of dorsiflexion at ankle
+124 ;; ___ Right ___ Left ___ Both
+125 ;; ___ Limitation of dorsiflexion at ankle to right angle
+126 ;; ___ Right ___ Left ___ Both
+127 ;; ___ Marked varus deformity ___ Right ___ Left ___ Both
+128 ;; ___ Other, describe (if the Veteran has dorsiflexion and varus deformity
+129 ;; due to other etiology than pes cavus, indicate other etiology): ______
+130 ;; ______________________________________________________________________
+131 ;;
+132 ;; 8. Malunion or nonunion of tarsal or metatarsal bones
+133 ;; Does the Veteran have malunion or nonunion of tarsal or metatarsal bones?
+134 ;; ___ Yes ___ No
+135 ;; Indicate severity and side affected:
+136 ;; ___ Moderate ___ Right ___ Left ___ Both
+137 ;; ___ Moderately severe ___ Right ___ Left ___ Both
+138 ;; ___ Severe ___ Right ___ Left ___ Both
+139 ;;
+140 ;; 9. Foot injuries
+141 ;; Does the Veteran have any other foot injuries?
+142 ;; ___ Yes ___ No
+143 ;; If yes, describe: __________________________________________________________
+144 ;; If yes, indicate severity and side affected:
+145 ;; ___ Moderate ___ Right ___ Left ___ Both
+146 ;; ___ Moderately severe ___ Right ___ Left ___ Both
+147 ;; ___ Severe ___ Right ___ Left ___ Both
+148 ;;^TOF^
+149 ;; 10. Bilateral weak foot
+150 ;; NOTE: For VA purposes, bilateral weak foot is a symptomatic condition
+151 ;; secondary to many constitutional conditions characterized by atrophy of
+152 ;; the musculature, disturbed circulation and weakness.
+153 ;;
+154 ;; Is there evidence of bilateral weak foot?
+155 ;; ___ Yes ___ No
+156 ;; If yes, describe and report underlying condition: __________________________
+157 ;;
+158 ;; 11. Other pertinent physical findings, complications, conditions, signs
+159 ;; and/or symptoms
+160 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+161 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+162 ;; section above?
+163 ;; ___ Yes ___ No
+164 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+165 ;; of all related scars greater than 39 square cm (6 square inches)?
+166 ;; ___ Yes ___ No
+167 ;; If yes, also complete a Scars Questionnaire.
+168 ;;
+169 ;; b. Does the Veteran have any other pertinent physical findings,
+170 ;; complications, conditions, signs and/or symptoms related to any
+171 ;; conditions listed in the Diagnosis section above?
+172 ;; ___ Yes ___ No
+173 ;; If yes, describe (brief summary): __________________________________________
+174 ;;
+175 ;; 12. Assistive devices
+176 ;; a. Does the Veteran use any assistive devices as a normal mode of
+177 ;; locomotion, although occasional locomotion by other methods may be possible?
+178 ;; ___ Yes ___ No
+179 ;; If yes, identify assistive devices used (check all that apply and indicate
+180 ;; frequency):
+181 ;; ___ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
+182 ;; ___ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
+183 ;; ___ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
+184 ;; ___ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
+185 ;; ___ Walker Frequency of use: __ Occasional __ Regular __ Constant
+186 ;; ___ Other: _______________________________________________________________
+187 ;; Frequency of use: __ Occasional __ Regular __ Constant
+188 ;;
+189 ;; b. If the Veteran uses any assistive devices, specify the condition and
+190 ;; identify the assistive device used for each condition: ______________________
+191 ;;
+192 ;; ____________________________________________________________________________
+193 ;;^TOF^
+194 ;; 13. Remaining effective function of the extremities
+195 ;; Due to the Veteran's foot condition, is there functional impairment of an
+196 ;; extremity such that no effective function remains other than that which would
+197 ;; be equally well served by an amputation with prosthesis? (Functions of the
+198 ;; upper extremity include grasping, manipulation, etc., while functions for the
+199 ;; lower extremity include balance and propulsion, etc.)
+200 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+201 ;; equally serve the Veteran.
+202 ;; ___ No
+203 ;; If yes, indicate extremities for which this applies:
+204 ;; ___ Right lower ___ Left lower
+205 ;;
+206 ;; For each checked extremity, describe loss of effective function, identify
+207 ;; the condition causing loss of function, and provide specific examples
+208 ;; (brief summary): ___________________________________________________________
+209 ;;
+210 ;; 14. Diagnostic Testing
+211 ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
+212 ;; arthritis must be confirmed by imaging studies. Once such arthritis has been
+213 ;; documented, no further imaging studies are required by VA, even if arthritis
+214 ;; has worsened.
+215 ;;
+216 ;; a. Have imaging studies of the foot been performed and are the results
+217 ;; available?
+218 ;; ___ Yes ___ No
+219 ;; If yes, are there abnormal findings?
+220 ;; ___ Yes ___ No
+221 ;; If yes, indicate findings:
+222 ;; ___ Degenerative or traumatic arthritis
+223 ;; Foot: ___ Right ___ Left ___ Both
+224 ;; Is degenerative or traumatic arthritis documented in multiple
+225 ;; joints of the same foot?
+226 ;; ___ Yes ___ No
+227 ;; If yes, indicate: ___ Right ___ Left ___ Both
+228 ;; ___ Other. Describe: ________________________________________________
+229 ;; Foot: ___ Right ___ Left ___ Both
+230 ;;
+231 ;; b. Are there any other significant diagnostic test findings and/or results?
+232 ;; ___ Yes ___ No
+233 ;; If yes, provide type of test or procedure, date and results (brief
+234 ;; summary):
+235 ;; ________________________________________________________________________
+236 ;;^TOF^
+237 ;; 15. Functional impact
+238 ;; Does the Veteran's foot condition impact his or her ability to work?
+239 ;; ___ Yes ___ No
+240 ;; If yes, describe the impact of each of the Veteran's foot conditions
+241 ;; providing one or more examples: ____________________________________________
+242 ;;
+243 ;; 16. Remarks, if any: _______________________________________________________
+244 ;; ____________________________________________________________________________
+245 ;;
+246 ;; Physician signature: _____________________________________ Date: ___________
+247 ;;
+248 ;; Physician printed name: ____________________________________________________
+249 ;;
+250 ;; Medical license #: _________________________________________________________
+251 ;;
+252 ;; Physician address: _________________________________________________________
+253 ;;
+254 ;; Phone: _____________________________ FAX: ______________________________
+255 ;;
+256 ;; NOTE: VA may request additional medical information, including additional
+257 ;; examinations if necessary to complete VA's review of the Veteran's application.
+258 ;;^END^
+259 QUIT
