- 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 Mar 13, 2025@20:51:17 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
