Home   Package List   Routine Alphabetical List   Global Alphabetical List   FileMan Files List   FileMan Sub-Files List   Package Component Lists   Package-Namespace Mapping  
Routine: DVBCQFM2

DVBCQFM2.m

Go to the documentation of this file. 
  1. DVBCQFM2 ;;ALB-CIOFO/ECF - FOOT MISCELLANEOUS QUESTIONNAIRE ; 20/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 a foot condition (other
  1.  ;; than flatfoot)?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, indicate diagnosis/es: (check all that apply) and complete
  1.  ;; appropriate section(s).
  1.  ;; Provide only diagnoses that pertain to foot conditions other than flatfoot:
  1.  ;;   ___ Morton's neuroma      ICD code: ______ Date of diagnosis: ___________
  1.  ;;   ___ Metatarsalgia         ICD code: ______ Date of diagnosis: ___________
  1.  ;;   ___ Hammer toes           ICD code: ______ Date of diagnosis: ___________
  1.  ;;   ___ Hallux valgus         ICD code: ______ Date of diagnosis: ___________
  1.  ;;   ___ Hallux rigidus        ICD code: ______ Date of diagnosis: ___________
  1.  ;;   ___ Claw foot (pes cavus) ICD code: ______ Date of diagnosis: ___________
  1.  ;;   ___ Malunion/nonunion of tarsal/metatarsal bones
  1.  ;;                             ICD code: ______ Date of diagnosis: ___________
  1.  ;;   ___ Foot injuries (specify): ____________
  1.  ;;                             ICD code: ______ Date of diagnosis: ___________
  1.  ;;   ___ Other foot conditions (specify): _____
  1.  ;;                             ICD code: ______ Date of diagnosis: ___________
  1.  ;;
  1.  ;; NOTE: If the Veteran has flatfoot, also complete the Flatfoot Questionnaire.
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;; Describe the history (including onset and course) of the Veteran's current
  1.  ;; foot condition (brief summary): ____________________________________________
  1.  ;;
  1.  ;; 3. Morton's neuroma (Morton's disease) and metatarsalgia
  1.  ;; a. Does the Veteran have Morton's neuroma?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:  ___ Right ___ Left ___ Both
  1.  ;;
  1.  ;; b. Does the Veteran have metatarsalgia?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:  ___ Right ___ Left ___ Both
  1.  ;;
  1.  ;; 4. Hammer toe
  1.  ;; Does the Veteran have hammer toes?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If yes, which toes are affected on each side?
  1.  ;;     Right:
  1.  ;;     ___ None        ___ Great toe    ___ Second toe
  1.  ;;     ___ Third toe   ___ Fourth toe   ___ Little toe
  1.  ;;     Left:
  1.  ;;     ___ None        ___ Great toe    ___ Second toe
  1.  ;;     ___ Third toe   ___ Fourth toe   ___ Little toe
  1.  ;;
  1.  ;; 5. Hallux valgus
  1.  ;; Does the Veteran now have or has he/she ever had hallux valgus?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete the following:
  1.  ;;
  1.  ;; a. Does the Veteran have symptoms due to a hallux valgus condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate severity (check all that apply):
  1.  ;;    ___ Mild or moderate symptoms
  1.  ;;          Side affected:  ___ Right ___ Left ___ Both
  1.  ;;    ___ Severe symptoms, with function equivalent to amputation of great toe
  1.  ;;          Side affected:  ___ Right ___ Left ___ Both
  1.  ;;
  1.  ;; b. Has the Veteran had surgery for hallux valgus?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate type of surgery and side affected:
  1.  ;;    ___ Resection of metatarsal head
  1.  ;;          Date of surgery: ________________
  1.  ;;          Side affected:  ___ Right  ___ Left  ___ Both
  1.  ;;    ___ Metatarsal osteotomy/metatarsal head osteotomy (equivalent to
  1.  ;;        metatarsal head resection)
  1.  ;;          Date of surgery: ________________
  1.  ;;          Side affected:  ___ Right  ___ Left  ___ Both
  1.  ;;    ___ Other surgery for hallux valgus, describe: _________
  1.  ;;          Date of surgery: ________________
  1.  ;;          Side affected:  ___ Right  ___ Left  ___ Both
  1.  ;;
  1.  ;; 6. Hallux rigidus
  1.  ;; Does the Veteran have hallux rigidus?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, does the Veteran have symptoms due to hallux rigidus?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate severity (check all that apply):
  1.  ;;    ___ Mild or moderate symptoms
  1.  ;;          Side affected:  ___ Right  ___ Left  ___ Both
  1.  ;;    ___ Severe symptoms, with function equivalent to amputation of great toe
  1.  ;;          Side affected:  ___ Right  ___ Left  ___ Both
  1.  ;;
  1.  ;; 7. Pes cavus (claw foot)
  1.  ;; Does the Veteran have acquired claw foot (pes cavus)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete the following:
  1.  ;;
  1.  ;; a. Effect on toes due to pes cavus (check all that apply)
  1.  ;;    ___ None                              ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Great toe dorsiflexed             ___ Right   ___ Left   ___ Both
  1.  ;;    ___ All toes tending to dorsiflexion  ___ Right   ___ Left   ___ Both
  1.  ;;    ___ All toes hammer toes              ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Other, describe (if there is an effect on toes due to other etiology
  1.  ;;        than pes cavus, indicate other etiology): ___________________________
  1.  ;;
  1.  ;; b. Pain and tenderness due to pes cavus (check all that apply)
  1.  ;;   ___ None                               ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Definite tenderness under metatarsal heads
  1.  ;;                                          ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Marked tenderness under metatarsal heads
  1.  ;;                                          ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Very painful callosities           ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Other, describe (if the Veteran has pain and tenderness due to other
  1.  ;;       etiology than pes cavus, indicate other etiology): ___________________
  1.  ;;
  1.  ;; c. Effect on plantar fascia due to pes cavus (check all that apply)
  1.  ;;   ___ None                               ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Shortened plantar fascia           ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Marked contraction of plantar fascia with
  1.  ;;       dropped forefoot                   ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Other, describe (if there is an effect on plantar fascia due to other
  1.  ;;       etiology than pes cavus, indicate other etiology): ___________________
  1.  ;;
  1.  ;; d. Dorsiflexion and varus deformity due to pes cavus (check all that apply)
  1.  ;;   ___ None                               ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Some limitation of dorsiflexion at ankle
  1.  ;;                                          ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Limitation of dorsiflexion at ankle to right angle
  1.  ;;                                          ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Marked varus deformity             ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Other, describe (if the Veteran has dorsiflexion and varus deformity
  1.  ;;       due to other etiology than pes cavus, indicate other etiology): ______
  1.  ;;       ______________________________________________________________________
  1.  ;;
  1.  ;; 8. Malunion or nonunion of tarsal or metatarsal bones
  1.  ;; Does the Veteran have malunion or nonunion of tarsal or metatarsal bones?
  1.  ;; ___ Yes   ___ No
  1.  ;;     Indicate severity and side affected:
  1.  ;;     ___ Moderate             ___ Right ___ Left ___ Both
  1.  ;;     ___ Moderately severe    ___ Right ___ Left ___ Both
  1.  ;;     ___ Severe               ___ Right ___ Left ___ Both
  1.  ;;
  1.  ;; 9. Foot injuries
  1.  ;; Does the Veteran have any other foot injuries?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe: __________________________________________________________
  1.  ;; If yes, indicate severity and side affected:
  1.  ;;     ___ Moderate             ___ Right ___ Left ___ Both
  1.  ;;     ___ Moderately severe    ___ Right ___ Left ___ Both
  1.  ;;     ___ Severe               ___ Right ___ Left ___ Both
  1.  ;;^TOF^
  1.  ;; 10. Bilateral weak foot
  1.  ;; NOTE: For VA purposes, bilateral weak foot is a symptomatic condition
  1.  ;; secondary to many constitutional conditions characterized by atrophy of
  1.  ;; the musculature, disturbed circulation and weakness.
  1.  ;;
  1.  ;; Is there evidence of bilateral weak foot?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe and report underlying condition: __________________________
  1.  ;;
  1.  ;; 11. 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.  ;;
  1.  ;; 12. Assistive devices
  1.  ;; a. Does the Veteran use any assistive devices as a normal mode of
  1.  ;; locomotion, although 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.  ;;   ___ 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.  ;;^TOF^
  1.  ;; 13. Remaining effective function of the extremities
  1.  ;; Due to the Veteran's foot condition, is there functional impairment of an
  1.  ;; extremity such that no effective function remains other than that which would
  1.  ;; be equally well served by an amputation with prosthesis? (Functions of the
  1.  ;; upper extremity include grasping, manipulation, etc., while functions for the
  1.  ;; 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.  ;;
  1.  ;;     For each checked extremity, describe loss of effective function, identify
  1.  ;;     the condition causing loss of function, and provide specific examples
  1.  ;; (brief summary): ___________________________________________________________
  1.  ;;
  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 been
  1.  ;; documented, no further imaging studies are required by VA, even if arthritis
  1.  ;; 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, are there abnormal findings?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If yes, indicate findings:
  1.  ;;        ___ Degenerative or traumatic arthritis
  1.  ;;            Foot: ___ Right   ___ Left   ___ Both
  1.  ;;            Is degenerative or traumatic arthritis documented in multiple
  1.  ;;            joints of the same foot?
  1.  ;;            ___ Yes   ___ No
  1.  ;;            If yes, indicate: ___ Right   ___ Left   ___ Both
  1.  ;;       ___ Other.  Describe: ________________________________________________
  1.  ;;            Foot: ___ 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.  ;;^TOF^
  1.  ;; 15. Functional impact
  1.  ;; Does the Veteran's foot condition impact his or her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe the impact of each of the Veteran's foot conditions
  1.  ;; providing one or more examples: ____________________________________________
  1.  ;;
  1.  ;; 16. Remarks, if any: _______________________________________________________
  1.  ;; ____________________________________________________________________________
  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 application.
  1.  ;;^END^
  1.  Q