DVBCQHF2 ;;ALB-CIOFO/ECF - HAND AND FINGER QUESTIONNAIRE ; 5/15/2011
;;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 hand or finger condition?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to hand conditions:
;; 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 hand conditions, list
;; using above format: ________________________________________________________
;;
;; 2. Medical history
;; a. Describe the history (including onset and course) of the Veteran's hand
;; condition (brief summary): _________________________________________________
;;
;; b. Dominant hand:
;; ___ Right ___ Left ___ Ambidextrous
;;
;; 3. Flare-ups
;; Does the Veteran report that flare-ups impact the function of the hand?
;; ___ Yes ___ No
;; If yes, document the Veteran's description of the impact of flare-ups in
;; his or her own words: ______________________________________________________
;;
;; 4. Initial range of motion (ROM) measurements
;; Measure ROM with a goniometer, rounding each measurement to the nearest 5
;; degrees. During the measurements, document the point at which painful
;; motion begins, evidenced by visible behavior such as facial expression,
;; wincing, etc. Report initial measurements below.
;;
;; Following the initial assessment of ROM, perform repetitive use testing.
;; For VA purposes, repetitive use testing must be included in all joint exams.
;; The VA has determined that 3 repetitions of ROM (at a minimum) can serve as
;; a representative test of the effect of repetitive use. After the initial
;; measurement, reassess ROM after 3 repetitions. Report post-test measurements
;; in section 5.
;;
;; a. Is there limitation of motion or evidence of painful motion for any
;; fingers or thumbs?
;; ___ Yes ___ No
;; If no, skip to section 5
;; If yes, indicate digits affected (check all that apply):
;; Right:
;; ___Thumb ___Index finger ___Long finger ___Ring finger ___Little finger
;; Left:
;; ___Thumb ___Index finger ___Long finger ___Ring finger ___Little finger
;;
;; b. Ability to oppose thumb: Is there a gap between the thumb pad and the
;; fingers?
;; ___ Yes ___ No
;; If yes, indicate distance of gap and side affected:
;; ___ Less than 1 inch (2.5 cm.) ___ Right ___ Left ___ Both
;; ___ 1 to 2 inches (2.5 to 5.1 cm.) ___ Right ___ Left ___ Both
;; ___ More than 2 inches (5.1 cm.) ___ Right ___ Left ___ Both
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___ Pain begins at gap of less ___ Right ___ Left ___ Both
;; than 1 inch (2.5 cm.)
;; ___ Pain begins at gap of 1 to ___ Right ___ Left ___ Both
;; 2 inches (2.5 to 5.1 cm.)
;; ___ Pain begins at gap of more ___ Right ___ Left ___ Both
;; than 2 inches (5.1 cm.)
;;
;; c. Finger flexion: Is there a gap between any fingertips and the proximal
;; transverse crease of the palm or evidence of painful motion in attempting
;; to touch the palm with the fingertips?
;; ___ Yes ___ No
;; If yes, indicate the gap:
;; ___ Gap less than 1 inch (2.5 cm)
;; Indicate fingers affected (check all that apply):
;; Right: ___Index finger ___Long finger ___ Ring finger ___Little finger
;; Left: ___Index finger ___Long finger ___ Ring finger ___Little finger
;; ___ Gap 1 inch (2.5 cm) or more
;; Indicate fingers affected (check all that apply):
;; Right: ___Index finger ___Long finger ___ Ring finger ___Little finger
;; Left: ___Index finger ___Long finger ___ Ring finger ___Little finger
;;^TOF^
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___ Painful motion begins at a gap of less than 1 inch (2.5 cm)
;; Indicate fingers affected (check all that apply):
;; Right: ___Index finger ___Long finger ___ Ring finger ___Little finger
;; Left: ___Index finger ___Long finger ___ Ring finger ___Little finger
;; ___ Painful motion begins at a gap of 1 inch (2.5 cm) or more
;; Indicate fingers affected (check all that apply):
;; Right: ___Index finger ___Long finger ___ Ring finger ___Little finger
;; Left: ___Index finger ___Long finger ___ Ring finger ___Little finger
;;
;; d. Finger extension: Is there limitation of extension or evidence of
;; painful motion for the index finger or long finger?
;; ___ Yes ___ No
;; If yes, indicate limitation of extension:
;; ___ Extension limited by no more than 30 degrees (unable to extend
;; finger fully, extension limited to between 0 and 30 degrees of flexion)
;; Indicate fingers affected: (check all that apply)
;; Right: ___ Index finger ___ Long finger
;; Left: ___ Index finger ___ Long finger
;; ___ Extension limited by more than 30 degrees (unable to extend finger
;; fully, extension limited to 31 degrees or more of flexion)
;; Indicate fingers affected: (check all that apply)
;; Right: ___ Index finger ___ Long finger
;; Left: ___ Index finger ___ Long finger
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___ Painful motion begins at extension of no more than 30 degrees (unable
;; to extend finger fully, painful extension begins between 0 and 30 degrees
;; of flexion)
;; Indicate fingers affected: (check all that apply)
;; Right: ___ Index finger ___ Long finger
;; Left: ___ Index finger ___ Long finger
;; ___ Painful motion begins at extension of more than 30 degrees (unable to
;; extend finger fully, painful extension begins at 31 degrees or more of
;; flexion)
;; Indicate fingers affected: (check all that apply)
;; Right: ___ Index finger ___ Long finger
;; Left: ___ Index finger ___ Long finger
;;
;; e. If ROM does not conform to the normal range of motion identified above
;; but is normal for this Veteran (for reasons other than a hand condition,
;; such as age, body habitus, neurologic disease), explain: ___________________
;; ____________________________________________________________________________
;;^TOF^
;; 5. ROM measurements after repetitive use testing
;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
;; ___ Yes ___ No If unable, provide reason: _____________________________
;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
;; If Veteran is able to perform repetitive-use testing, measure and report
;; ROM after a minimum of 3 repetitions:
;;
;; b. Is there additional limitation of motion for any fingers post-test?
;; ___ Yes ___ No
;; If yes, indicate digit(s) affected: (check all that apply)
;; Right:
;; ___Thumb ___Index finger ___Long finger ___Ring finger ___Little finger
;; Left:
;; ___Thumb ___Index finger ___Long finger ___Ring finger ___Little finger
;;
;; c. Ability to oppose thumb: Is there a gap between the thumb pad and the
;; fingers post-test?
;; ___ Yes ___ No
;; If yes, indicate distance of gap and side affected:
;; ___ Less than 1 inch (2.5 cm.) ___ Right ___ Left ___ Both
;; ___ 1 to 2 inches (2.5 to 5.1 cm.) ___ Right ___ Left ___ Both
;; ___ More than 2 inches (5.1 cm.) ___ Right ___ Left ___ Both
;;
;; d. Finger flexion: Is there a gap between any fingertips and the proximal
;; transverse crease of the palm in attempting to touch the palm with the
;; fingertips post-test?
;; ___ Yes ___ No
;; If yes, indicate the gap:
;; ___ Gap less than 1 inch (2.5 cm)
;; Indicate fingers affected (check all that apply):
;; Right: ___Index finger ___Long finger ___Ring finger ___Little finger
;; Left: ___Index finger ___Long finger ___Ring finger ___Little finger
;;
;; ___ Gap 1 inch (2.5 cm) or more
;; Indicate fingers affected (check all that apply):
;; Right: ___Index finger ___Long finger ___Ring finger ___Little finger
;; Left: ___Index finger ___Long finger ___Ring finger ___Little finger
;;^TOF^
;; e. Finger extension: Is there limitation of extension for the index finger
;; or long finger post-test?
;; ___ Yes ___ No
;; If yes, indicate limitation of extension:
;; ___ Extension limited by no more than 30 degrees (unable to extend finger
;; fully, extension limited to between 0 and 30 degrees of flexion)
;; Indicate fingers affected: (check all that apply)
;; Right: ___ Index finger ___ Long finger
;; Left: ___ Index finger ___ Long finger
;; ___ Extension limited by more than 30 degrees (unable to extend finger
;; fully, extension limited to 31 degrees or more of flexion)
;; Indicate fingers affected: (check all that apply)
;; Right: ___ Index finger ___ Long finger
;; Left: ___ Index finger ___ Long finger
;;
;; 6. Functional loss and additional limitation of ROM
;; The following section addresses reasons for functional loss, if present, and
;; additional loss of ROM after repetitive-use testing, if present. The VA defines
;; functional loss as the inability to perform normal working movements of the
;; body with normal excursion, strength, speed, coordination and/or endurance.
;;
;; a. Does the Veteran have any functional loss or functional impairment of
;; any of the fingers or thumbs?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have additional limitation in ROM of any of the
;; fingers or thumbs following repetitive-use testing?
;; ___ Yes ___ No
;;
;; c. If the Veteran has functional loss, functional impairment or additional
;; limitation of ROM of any of the fingers or thumbs after repetitive use,
;; indicate the contributing factors of disability below (check all that apply;
;; indicate digit and side affected):
;; ___ No functional loss for right hand, thumb or fingers
;; ___ No functional loss for left hand, thumb or fingers
;; ___ Less movement than normal
;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; ___ More movement than normal
;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; ___ Weakened movement
;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;;^TOF^
;; ___ Excess fatigability
;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; ___ Incoordination, impaired ability to execute skilled movements smoothly
;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; ___ Pain on movement
;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; ___ Swelling
;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; ___ Deformity
;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; ___ Atrophy of disuse
;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
;; finger finger finger finger
;; ___ Other, describe: ____________________________________________________
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQHF2 14716 printed Nov 22, 2024@16:56:46 Page 2
DVBCQHF2 ;;ALB-CIOFO/ECF - HAND AND FINGER QUESTIONNAIRE ; 5/15/2011
+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 hand or finger condition?
+7 ;; ___ Yes ___ No
+8 ;;
+9 ;; If yes, provide only diagnoses that pertain to hand conditions:
+10 ;; Diagnosis #1: ___________________
+11 ;; ICD code: ______________________
+12 ;; Date of diagnosis: ______________
+13 ;; Side affected: ___ Right ___ Left ___ Both
+14 ;;
+15 ;; Diagnosis #2: ___________________
+16 ;; ICD code: ______________________
+17 ;; Date of diagnosis: ______________
+18 ;; Side affected: ___ Right ___ Left ___ Both
+19 ;;
+20 ;; Diagnosis #3: ___________________
+21 ;; ICD code: ______________________
+22 ;; Date of diagnosis: ______________
+23 ;; Side affected: ___ Right ___ Left ___ Both
+24 ;;
+25 ;; If there are additional diagnoses that pertain to hand conditions, list
+26 ;; using above format: ________________________________________________________
+27 ;;
+28 ;; 2. Medical history
+29 ;; a. Describe the history (including onset and course) of the Veteran's hand
+30 ;; condition (brief summary): _________________________________________________
+31 ;;
+32 ;; b. Dominant hand:
+33 ;; ___ Right ___ Left ___ Ambidextrous
+34 ;;
+35 ;; 3. Flare-ups
+36 ;; Does the Veteran report that flare-ups impact the function of the hand?
+37 ;; ___ Yes ___ No
+38 ;; If yes, document the Veteran's description of the impact of flare-ups in
+39 ;; his or her own words: ______________________________________________________
+40 ;;
+41 ;; 4. Initial range of motion (ROM) measurements
+42 ;; Measure ROM with a goniometer, rounding each measurement to the nearest 5
+43 ;; degrees. During the measurements, document the point at which painful
+44 ;; motion begins, evidenced by visible behavior such as facial expression,
+45 ;; wincing, etc. Report initial measurements below.
+46 ;;
+47 ;; Following the initial assessment of ROM, perform repetitive use testing.
+48 ;; For VA purposes, repetitive use testing must be included in all joint exams.
+49 ;; The VA has determined that 3 repetitions of ROM (at a minimum) can serve as
+50 ;; a representative test of the effect of repetitive use. After the initial
+51 ;; measurement, reassess ROM after 3 repetitions. Report post-test measurements
+52 ;; in section 5.
+53 ;;
+54 ;; a. Is there limitation of motion or evidence of painful motion for any
+55 ;; fingers or thumbs?
+56 ;; ___ Yes ___ No
+57 ;; If no, skip to section 5
+58 ;; If yes, indicate digits affected (check all that apply):
+59 ;; Right:
+60 ;; ___Thumb ___Index finger ___Long finger ___Ring finger ___Little finger
+61 ;; Left:
+62 ;; ___Thumb ___Index finger ___Long finger ___Ring finger ___Little finger
+63 ;;
+64 ;; b. Ability to oppose thumb: Is there a gap between the thumb pad and the
+65 ;; fingers?
+66 ;; ___ Yes ___ No
+67 ;; If yes, indicate distance of gap and side affected:
+68 ;; ___ Less than 1 inch (2.5 cm.) ___ Right ___ Left ___ Both
+69 ;; ___ 1 to 2 inches (2.5 to 5.1 cm.) ___ Right ___ Left ___ Both
+70 ;; ___ More than 2 inches (5.1 cm.) ___ Right ___ Left ___ Both
+71 ;;
+72 ;; Select where objective evidence of painful motion begins:
+73 ;; ___ No objective evidence of painful motion
+74 ;; ___ Pain begins at gap of less ___ Right ___ Left ___ Both
+75 ;; than 1 inch (2.5 cm.)
+76 ;; ___ Pain begins at gap of 1 to ___ Right ___ Left ___ Both
+77 ;; 2 inches (2.5 to 5.1 cm.)
+78 ;; ___ Pain begins at gap of more ___ Right ___ Left ___ Both
+79 ;; than 2 inches (5.1 cm.)
+80 ;;
+81 ;; c. Finger flexion: Is there a gap between any fingertips and the proximal
+82 ;; transverse crease of the palm or evidence of painful motion in attempting
+83 ;; to touch the palm with the fingertips?
+84 ;; ___ Yes ___ No
+85 ;; If yes, indicate the gap:
+86 ;; ___ Gap less than 1 inch (2.5 cm)
+87 ;; Indicate fingers affected (check all that apply):
+88 ;; Right: ___Index finger ___Long finger ___ Ring finger ___Little finger
+89 ;; Left: ___Index finger ___Long finger ___ Ring finger ___Little finger
+90 ;; ___ Gap 1 inch (2.5 cm) or more
+91 ;; Indicate fingers affected (check all that apply):
+92 ;; Right: ___Index finger ___Long finger ___ Ring finger ___Little finger
+93 ;; Left: ___Index finger ___Long finger ___ Ring finger ___Little finger
+94 ;;^TOF^
+95 ;; Select where objective evidence of painful motion begins:
+96 ;; ___ No objective evidence of painful motion
+97 ;; ___ Painful motion begins at a gap of less than 1 inch (2.5 cm)
+98 ;; Indicate fingers affected (check all that apply):
+99 ;; Right: ___Index finger ___Long finger ___ Ring finger ___Little finger
+100 ;; Left: ___Index finger ___Long finger ___ Ring finger ___Little finger
+101 ;; ___ Painful motion begins at a gap of 1 inch (2.5 cm) or more
+102 ;; Indicate fingers affected (check all that apply):
+103 ;; Right: ___Index finger ___Long finger ___ Ring finger ___Little finger
+104 ;; Left: ___Index finger ___Long finger ___ Ring finger ___Little finger
+105 ;;
+106 ;; d. Finger extension: Is there limitation of extension or evidence of
+107 ;; painful motion for the index finger or long finger?
+108 ;; ___ Yes ___ No
+109 ;; If yes, indicate limitation of extension:
+110 ;; ___ Extension limited by no more than 30 degrees (unable to extend
+111 ;; finger fully, extension limited to between 0 and 30 degrees of flexion)
+112 ;; Indicate fingers affected: (check all that apply)
+113 ;; Right: ___ Index finger ___ Long finger
+114 ;; Left: ___ Index finger ___ Long finger
+115 ;; ___ Extension limited by more than 30 degrees (unable to extend finger
+116 ;; fully, extension limited to 31 degrees or more of flexion)
+117 ;; Indicate fingers affected: (check all that apply)
+118 ;; Right: ___ Index finger ___ Long finger
+119 ;; Left: ___ Index finger ___ Long finger
+120 ;;
+121 ;; Select where objective evidence of painful motion begins:
+122 ;; ___ No objective evidence of painful motion
+123 ;; ___ Painful motion begins at extension of no more than 30 degrees (unable
+124 ;; to extend finger fully, painful extension begins between 0 and 30 degrees
+125 ;; of flexion)
+126 ;; Indicate fingers affected: (check all that apply)
+127 ;; Right: ___ Index finger ___ Long finger
+128 ;; Left: ___ Index finger ___ Long finger
+129 ;; ___ Painful motion begins at extension of more than 30 degrees (unable to
+130 ;; extend finger fully, painful extension begins at 31 degrees or more of
+131 ;; flexion)
+132 ;; Indicate fingers affected: (check all that apply)
+133 ;; Right: ___ Index finger ___ Long finger
+134 ;; Left: ___ Index finger ___ Long finger
+135 ;;
+136 ;; e. If ROM does not conform to the normal range of motion identified above
+137 ;; but is normal for this Veteran (for reasons other than a hand condition,
+138 ;; such as age, body habitus, neurologic disease), explain: ___________________
+139 ;; ____________________________________________________________________________
+140 ;;^TOF^
+141 ;; 5. ROM measurements after repetitive use testing
+142 ;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
+143 ;; ___ Yes ___ No If unable, provide reason: _____________________________
+144 ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
+145 ;; If Veteran is able to perform repetitive-use testing, measure and report
+146 ;; ROM after a minimum of 3 repetitions:
+147 ;;
+148 ;; b. Is there additional limitation of motion for any fingers post-test?
+149 ;; ___ Yes ___ No
+150 ;; If yes, indicate digit(s) affected: (check all that apply)
+151 ;; Right:
+152 ;; ___Thumb ___Index finger ___Long finger ___Ring finger ___Little finger
+153 ;; Left:
+154 ;; ___Thumb ___Index finger ___Long finger ___Ring finger ___Little finger
+155 ;;
+156 ;; c. Ability to oppose thumb: Is there a gap between the thumb pad and the
+157 ;; fingers post-test?
+158 ;; ___ Yes ___ No
+159 ;; If yes, indicate distance of gap and side affected:
+160 ;; ___ Less than 1 inch (2.5 cm.) ___ Right ___ Left ___ Both
+161 ;; ___ 1 to 2 inches (2.5 to 5.1 cm.) ___ Right ___ Left ___ Both
+162 ;; ___ More than 2 inches (5.1 cm.) ___ Right ___ Left ___ Both
+163 ;;
+164 ;; d. Finger flexion: Is there a gap between any fingertips and the proximal
+165 ;; transverse crease of the palm in attempting to touch the palm with the
+166 ;; fingertips post-test?
+167 ;; ___ Yes ___ No
+168 ;; If yes, indicate the gap:
+169 ;; ___ Gap less than 1 inch (2.5 cm)
+170 ;; Indicate fingers affected (check all that apply):
+171 ;; Right: ___Index finger ___Long finger ___Ring finger ___Little finger
+172 ;; Left: ___Index finger ___Long finger ___Ring finger ___Little finger
+173 ;;
+174 ;; ___ Gap 1 inch (2.5 cm) or more
+175 ;; Indicate fingers affected (check all that apply):
+176 ;; Right: ___Index finger ___Long finger ___Ring finger ___Little finger
+177 ;; Left: ___Index finger ___Long finger ___Ring finger ___Little finger
+178 ;;^TOF^
+179 ;; e. Finger extension: Is there limitation of extension for the index finger
+180 ;; or long finger post-test?
+181 ;; ___ Yes ___ No
+182 ;; If yes, indicate limitation of extension:
+183 ;; ___ Extension limited by no more than 30 degrees (unable to extend finger
+184 ;; fully, extension limited to between 0 and 30 degrees of flexion)
+185 ;; Indicate fingers affected: (check all that apply)
+186 ;; Right: ___ Index finger ___ Long finger
+187 ;; Left: ___ Index finger ___ Long finger
+188 ;; ___ Extension limited by more than 30 degrees (unable to extend finger
+189 ;; fully, extension limited to 31 degrees or more of flexion)
+190 ;; Indicate fingers affected: (check all that apply)
+191 ;; Right: ___ Index finger ___ Long finger
+192 ;; Left: ___ Index finger ___ Long finger
+193 ;;
+194 ;; 6. Functional loss and additional limitation of ROM
+195 ;; The following section addresses reasons for functional loss, if present, and
+196 ;; additional loss of ROM after repetitive-use testing, if present. The VA defines
+197 ;; functional loss as the inability to perform normal working movements of the
+198 ;; body with normal excursion, strength, speed, coordination and/or endurance.
+199 ;;
+200 ;; a. Does the Veteran have any functional loss or functional impairment of
+201 ;; any of the fingers or thumbs?
+202 ;; ___ Yes ___ No
+203 ;;
+204 ;; b. Does the Veteran have additional limitation in ROM of any of the
+205 ;; fingers or thumbs following repetitive-use testing?
+206 ;; ___ Yes ___ No
+207 ;;
+208 ;; c. If the Veteran has functional loss, functional impairment or additional
+209 ;; limitation of ROM of any of the fingers or thumbs after repetitive use,
+210 ;; indicate the contributing factors of disability below (check all that apply;
+211 ;; indicate digit and side affected):
+212 ;; ___ No functional loss for right hand, thumb or fingers
+213 ;; ___ No functional loss for left hand, thumb or fingers
+214 ;; ___ Less movement than normal
+215 ;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+216 ;; finger finger finger finger
+217 ;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+218 ;; finger finger finger finger
+219 ;; ___ More movement than normal
+220 ;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+221 ;; finger finger finger finger
+222 ;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+223 ;; finger finger finger finger
+224 ;; ___ Weakened movement
+225 ;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+226 ;; finger finger finger finger
+227 ;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+228 ;; finger finger finger finger
+229 ;;^TOF^
+230 ;; ___ Excess fatigability
+231 ;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+232 ;; finger finger finger finger
+233 ;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+234 ;; finger finger finger finger
+235 ;; ___ Incoordination, impaired ability to execute skilled movements smoothly
+236 ;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+237 ;; finger finger finger finger
+238 ;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+239 ;; finger finger finger finger
+240 ;; ___ Pain on movement
+241 ;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+242 ;; finger finger finger finger
+243 ;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+244 ;; finger finger finger finger
+245 ;; ___ Swelling
+246 ;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+247 ;; finger finger finger finger
+248 ;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+249 ;; finger finger finger finger
+250 ;; ___ Deformity
+251 ;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+252 ;; finger finger finger finger
+253 ;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+254 ;; finger finger finger finger
+255 ;; ___ Atrophy of disuse
+256 ;; Right: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+257 ;; finger finger finger finger
+258 ;; Left: ___ All ___ Thumb ___ Index ___ Long ___ Ring ___ Little
+259 ;; finger finger finger finger
+260 ;; ___ Other, describe: ____________________________________________________
+261 ;;
+262 QUIT
