DVBCQHF3 ;;ALB-CIOFO/ECF - HAND AND FINGER QUESTIONNAIRE ; 8/JUN/2011
;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
;
TXT ;
;; 7. Pain (pain on palpation)
;; Does the Veteran have tenderness or pain to palpation for joints or soft
;; tissue of either hand, including thumb and fingers
;; ___ Yes ___ No
;; If yes, side affected: ___ Right ___ Left ___ Both
;;
;; 8. Muscle strength testing
;; Rate strength according to the following scale:
;; 0/5 No muscle movement
;; 1/5 Palpable or visible muscle contraction, but no joint movement
;; 2/5 Active movement with gravity eliminated
;; 3/5 Active movement against gravity
;; 4/5 Active movement against some resistance
;; 5/5 Normal strength
;; Hand grip:
;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;;^TOF^
;; 9. Ankylosis
;; a. Does the Veteran have ankylosis of the thumb and/or fingers?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; Right thumb:
;; ___ Carpometacarpal joint ankylosis:
;; ___ In extension ___ In full flexion ___ In rotation or angulation
;; ___ Thumb is abducted and rotated so that the thumb pad faces the
;; finger pads
;; ___ Interphalangeal joint ankylosis:
;; ___ In extension ___ In full flexion ___ In rotation or angulation
;; ___ Thumb is abducted and rotated so that the thumb pad faces the
;; finger pads
;; ___ There is a gap of more than two inches (5.1 cm.) between the thumb
;; pad and the fingers, with the thumb attempting to oppose the fingers.
;; ___ There is a gap of two inches (5.1 cm.) or less between the thumb
;; pad and the fingers, with the thumb attempting to oppose the fingers.
;;
;; Left thumb:
;; ___ Carpometacarpal joint ankylosis:
;; ___ In extension ___ In full flexion ___ In rotation or angulation
;; ___ Thumb is abducted and rotated so that the thumb pad faces the
;; finger pads
;; ___ Interphalangeal joint ankylosis:
;; ___ In extension ___ In full flexion ___ In rotation or angulation
;; ___ Thumb is abducted and rotated so that the thumb pad faces the
;; finger pads
;; ___ There is a gap of more than two inches (5.1 cm.) between the thumb
;; pad and the fingers, with the thumb attempting to oppose the fingers.
;; ___ There is a gap of two inches (5.1 cm.) or less between the thumb
;; pad and the fingers, with the thumb attempting to oppose the fingers.
;;
;; Right:
;; ___ Index finger ___ Long finger ___ Ring finger ___ Little finger
;; ___ Metacarpophalangeal joint ankylosis:
;; ___ In extension ___ In full flexion
;; ___ In rotation or angulation
;; ___ Flexed to 30 degrees
;; ___ Proximal interphalangeal joint ankylosis:
;; ___ In extension ___ In full flexion
;; ___ In rotation or angulation
;; ___ Flexed to 30 degrees
;; ___ There is a gap of more than two inches (5.1 cm.) between the
;; fingertip(s) and the proximal transverse crease of the palm,
;; with the finger(s) flexed to the extent possible.
;; ___ There is a gap of two inches (5.1 cm.) or less between the
;; fingertip(s) and the proximal transverse crease of the palm,
;; with the finger(s) flexed to the extent possible.
;;^TOF^
;; Left:
;; ___ Index finger ___ Long finger ___ Ring finger ___ Little finger
;; ___ Metacarpophalangeal joint ankylosis:
;; ___ In extension ___ In full flexion
;; ___ In rotation or angulation
;; ___ Flexed to 30 degrees
;; ___ Proximal interphalangeal joint ankylosis:
;; ___ In extension ___ In full flexion
;; ___ In rotation or angulation
;; ___ Flexed to 30 degrees
;; ___ There is a gap of more than two inches (5.1 cm.) between the
;; fingertip(s) and the proximal transverse crease of the palm,
;; with the finger(s) flexed to the extent possible.
;; ___ There is a gap of two inches (5.1 cm.) or less between the
;; fingertip(s) and the proximal transverse crease of the palm,
;; with the finger(s) flexed to the extent possible.
;;
;; b. If there is ankylosis of more than one finger, provide details using
;; above descriptions: ________________________________________________________
;;
;; c. Does the ankylosis condition result in limitation of motion of other
;; digits or interference with overall function of the hand?
;; ___ Yes ___ No
;; If yes, describe: __________________________________________________________
;;
;; 10. 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): __________________________________________
;;
;; 11. Assistive devices and remaining function of the extremities
;; a. Does the Veteran use any assistive devices?
;; ___ Yes ___ No
;; If yes, identify assistive devices used (check all that apply and indicate
;; frequency):
;; ___ Brace(s)
;; 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: _____________________
;; ____________________________________________________________________________
;;
;; 12. Remaining effective function of the extremities
;; Due to the Veteran's hand, finger or thumb conditions, 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 upper ___ Left upper
;; For each checked extremity, identify the condition causing loss of function,
;; describe loss of effective function and provide specific examples (brief
;; summary): _______________________________________________________________
;;
;; 13. Diagnostic Testing
;; The diagnosis of arthritis must be confirmed by imaging studies. Once
;; arthritis has been documented, no further imaging studies are required by
;; VA, even if arthritis has worsened.
;; a. Have imaging studies of the hands 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
;; Hand: ___ Right ___ Left ___ Both
;; Is degenerative or traumatic arthritis documented in multiple
;; joints of the same hand, including thumb and fingers?
;; ___ Yes ___ No
;; If yes, indicate hand: ___ Right ___ Left ___ Both
;; ___ Other. Describe: ________________________________________________
;; Hand: ___ 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^
;; 14. Functional impact
;; Do the Veteran's hand, thumb, or finger conditions impact his or her
;; ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's hand, thumb and/or
;; finger conditions, providing one or more examples: __________________________
;;
;; 15. 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[HDVBCQHF3 9707 printed Apr 09, 2024@20:59:27 Page 2
DVBCQHF3 ;;ALB-CIOFO/ECF - HAND AND FINGER QUESTIONNAIRE ; 8/JUN/2011
+1 ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; 7. Pain (pain on palpation)
+2 ;; Does the Veteran have tenderness or pain to palpation for joints or soft
+3 ;; tissue of either hand, including thumb and fingers
+4 ;; ___ Yes ___ No
+5 ;; If yes, side affected: ___ Right ___ Left ___ Both
+6 ;;
+7 ;; 8. Muscle strength testing
+8 ;; Rate strength according to the following scale:
+9 ;; 0/5 No muscle movement
+10 ;; 1/5 Palpable or visible muscle contraction, but no joint movement
+11 ;; 2/5 Active movement with gravity eliminated
+12 ;; 3/5 Active movement against gravity
+13 ;; 4/5 Active movement against some resistance
+14 ;; 5/5 Normal strength
+15 ;; Hand grip:
+16 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+17 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+18 ;;^TOF^
+19 ;; 9. Ankylosis
+20 ;; a. Does the Veteran have ankylosis of the thumb and/or fingers?
+21 ;; ___ Yes ___ No
+22 ;; If yes, check all that apply:
+23 ;; Right thumb:
+24 ;; ___ Carpometacarpal joint ankylosis:
+25 ;; ___ In extension ___ In full flexion ___ In rotation or angulation
+26 ;; ___ Thumb is abducted and rotated so that the thumb pad faces the
+27 ;; finger pads
+28 ;; ___ Interphalangeal joint ankylosis:
+29 ;; ___ In extension ___ In full flexion ___ In rotation or angulation
+30 ;; ___ Thumb is abducted and rotated so that the thumb pad faces the
+31 ;; finger pads
+32 ;; ___ There is a gap of more than two inches (5.1 cm.) between the thumb
+33 ;; pad and the fingers, with the thumb attempting to oppose the fingers.
+34 ;; ___ There is a gap of two inches (5.1 cm.) or less between the thumb
+35 ;; pad and the fingers, with the thumb attempting to oppose the fingers.
+36 ;;
+37 ;; Left thumb:
+38 ;; ___ Carpometacarpal joint ankylosis:
+39 ;; ___ In extension ___ In full flexion ___ In rotation or angulation
+40 ;; ___ Thumb is abducted and rotated so that the thumb pad faces the
+41 ;; finger pads
+42 ;; ___ Interphalangeal joint ankylosis:
+43 ;; ___ In extension ___ In full flexion ___ In rotation or angulation
+44 ;; ___ Thumb is abducted and rotated so that the thumb pad faces the
+45 ;; finger pads
+46 ;; ___ There is a gap of more than two inches (5.1 cm.) between the thumb
+47 ;; pad and the fingers, with the thumb attempting to oppose the fingers.
+48 ;; ___ There is a gap of two inches (5.1 cm.) or less between the thumb
+49 ;; pad and the fingers, with the thumb attempting to oppose the fingers.
+50 ;;
+51 ;; Right:
+52 ;; ___ Index finger ___ Long finger ___ Ring finger ___ Little finger
+53 ;; ___ Metacarpophalangeal joint ankylosis:
+54 ;; ___ In extension ___ In full flexion
+55 ;; ___ In rotation or angulation
+56 ;; ___ Flexed to 30 degrees
+57 ;; ___ Proximal interphalangeal joint ankylosis:
+58 ;; ___ In extension ___ In full flexion
+59 ;; ___ In rotation or angulation
+60 ;; ___ Flexed to 30 degrees
+61 ;; ___ There is a gap of more than two inches (5.1 cm.) between the
+62 ;; fingertip(s) and the proximal transverse crease of the palm,
+63 ;; with the finger(s) flexed to the extent possible.
+64 ;; ___ There is a gap of two inches (5.1 cm.) or less between the
+65 ;; fingertip(s) and the proximal transverse crease of the palm,
+66 ;; with the finger(s) flexed to the extent possible.
+67 ;;^TOF^
+68 ;; Left:
+69 ;; ___ Index finger ___ Long finger ___ Ring finger ___ Little finger
+70 ;; ___ Metacarpophalangeal joint ankylosis:
+71 ;; ___ In extension ___ In full flexion
+72 ;; ___ In rotation or angulation
+73 ;; ___ Flexed to 30 degrees
+74 ;; ___ Proximal interphalangeal joint ankylosis:
+75 ;; ___ In extension ___ In full flexion
+76 ;; ___ In rotation or angulation
+77 ;; ___ Flexed to 30 degrees
+78 ;; ___ There is a gap of more than two inches (5.1 cm.) between the
+79 ;; fingertip(s) and the proximal transverse crease of the palm,
+80 ;; with the finger(s) flexed to the extent possible.
+81 ;; ___ There is a gap of two inches (5.1 cm.) or less between the
+82 ;; fingertip(s) and the proximal transverse crease of the palm,
+83 ;; with the finger(s) flexed to the extent possible.
+84 ;;
+85 ;; b. If there is ankylosis of more than one finger, provide details using
+86 ;; above descriptions: ________________________________________________________
+87 ;;
+88 ;; c. Does the ankylosis condition result in limitation of motion of other
+89 ;; digits or interference with overall function of the hand?
+90 ;; ___ Yes ___ No
+91 ;; If yes, describe: __________________________________________________________
+92 ;;
+93 ;; 10. Other pertinent physical findings, complications, conditions, signs
+94 ;; and/or symptoms
+95 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+96 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+97 ;; section above?
+98 ;; ___ Yes ___ No
+99 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+100 ;; of all related scars greater than 39 square cm (6 square inches)?
+101 ;; ___ Yes ___ No
+102 ;; If yes, also complete a Scars Questionnaire.
+103 ;;
+104 ;; b. Does the Veteran have any other pertinent physical findings,
+105 ;; complications, conditions, signs and/or symptoms related to any conditions
+106 ;; listed in the Diagnosis section above?
+107 ;; ___ Yes ___ No
+108 ;; If yes, describe (brief summary): __________________________________________
+109 ;;
+110 ;; 11. Assistive devices and remaining function of the extremities
+111 ;; a. Does the Veteran use any assistive devices?
+112 ;; ___ Yes ___ No
+113 ;; If yes, identify assistive devices used (check all that apply and indicate
+114 ;; frequency):
+115 ;; ___ Brace(s)
+116 ;; Frequency of use: ___ Occasional ___ Regular ___Constant
+117 ;; ___ Other: _____________
+118 ;; Frequency of use: ___ Occasional ___ Regular ___Constant
+119 ;;
+120 ;; b. If the Veteran uses any assistive devices, specify the condition and
+121 ;; identify the assistive device used for each condition: _____________________
+122 ;; ____________________________________________________________________________
+123 ;;
+124 ;; 12. Remaining effective function of the extremities
+125 ;; Due to the Veteran's hand, finger or thumb conditions, is there functional
+126 ;; impairment of an extremity such that no effective function remains other
+127 ;; than that which would be equally well served by an amputation with
+128 ;; prosthesis? (Functions of the upper extremity include grasping,
+129 ;; manipulation, etc., while functions for the lower extremity include
+130 ;; balance and propulsion, etc.)
+131 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+132 ;; equally serve the Veteran.
+133 ;; ___ No
+134 ;; If yes, indicate extremities for which this applies:
+135 ;; ___ Right upper ___ Left upper
+136 ;; For each checked extremity, identify the condition causing loss of function,
+137 ;; describe loss of effective function and provide specific examples (brief
+138 ;; summary): _______________________________________________________________
+139 ;;
+140 ;; 13. Diagnostic Testing
+141 ;; The diagnosis of arthritis must be confirmed by imaging studies. Once
+142 ;; arthritis has been documented, no further imaging studies are required by
+143 ;; VA, even if arthritis has worsened.
+144 ;; a. Have imaging studies of the hands been performed and are the results
+145 ;; available?
+146 ;; ___ Yes ___ No
+147 ;;
+148 ;; If yes, are there abnormal findings?
+149 ;; ___ Yes ___ No
+150 ;; If yes, indicate findings:
+151 ;; ___ Degenerative or traumatic arthritis
+152 ;; Hand: ___ Right ___ Left ___ Both
+153 ;; Is degenerative or traumatic arthritis documented in multiple
+154 ;; joints of the same hand, including thumb and fingers?
+155 ;; ___ Yes ___ No
+156 ;; If yes, indicate hand: ___ Right ___ Left ___ Both
+157 ;; ___ Other. Describe: ________________________________________________
+158 ;; Hand: ___ Right ___ Left ___ Both
+159 ;;
+160 ;; b. Are there any other significant diagnostic test findings and/or results?
+161 ;; ___ Yes ___ No
+162 ;; If yes, provide type of test or procedure, date and results (brief summary):
+163 ;; ____________________________________________________________________________
+164 ;;^TOF^
+165 ;; 14. Functional impact
+166 ;; Do the Veteran's hand, thumb, or finger conditions impact his or her
+167 ;; ability to work?
+168 ;; ___ Yes ___ No
+169 ;; If yes, describe the impact of each of the Veteran's hand, thumb and/or
+170 ;; finger conditions, providing one or more examples: __________________________
+171 ;;
+172 ;; 15. Remarks, if any: _______________________________________________________
+173 ;;
+174 ;; Physician signature: ____________________________________ Date: ____________
+175 ;;
+176 ;; Physician printed name: ____________________________________________________
+177 ;;
+178 ;; Medical license #: _________________________________________________________
+179 ;;
+180 ;; Physician address: _________________________________________________________
+181 ;;
+182 ;; Phone: _____________________________ FAX: ______________________________
+183 ;;
+184 ;; NOTE: VA may request additional medical information, including additional
+185 ;; examinations if necessary to complete VA's review of the Veteran's application.
+186 ;;^END^
+187 QUIT
