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Routine: DVBCQHF3

DVBCQHF3.m

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  1. DVBCQHF3 ;;ALB-CIOFO/ECF -  HAND AND FINGER QUESTIONNAIRE ; 8/JUN/2011
  1.  ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; 7. Pain (pain on palpation)
  1.  ;; Does the Veteran have tenderness or pain to palpation for joints or soft
  1.  ;; tissue of either hand, including thumb and fingers
  1.  ;; ___ Yes   ___ No
  1.  ;;    If yes, side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; 8. Muscle strength testing
  1.  ;;       Rate strength according to the following scale:
  1.  ;;       0/5 No muscle movement
  1.  ;;       1/5 Palpable or visible muscle contraction, but no joint movement
  1.  ;;       2/5 Active movement with gravity eliminated
  1.  ;;       3/5 Active movement against gravity
  1.  ;;       4/5 Active movement against some resistance
  1.  ;;       5/5 Normal strength
  1.  ;;    Hand grip:
  1.  ;;       Right:  ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;       Left:   ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;^TOF^
  1.  ;; 9. Ankylosis
  1.  ;; a. Does the Veteran have ankylosis of the thumb and/or fingers?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;; Right thumb:
  1.  ;;    ___ Carpometacarpal joint ankylosis:
  1.  ;;       ___ In extension  ___ In full flexion  ___ In rotation or angulation
  1.  ;;       ___ Thumb is abducted and rotated so that the thumb pad faces the
  1.  ;;           finger pads
  1.  ;;    ___ Interphalangeal joint ankylosis:
  1.  ;;       ___ In extension  ___ In full flexion  ___ In rotation or angulation
  1.  ;;       ___ Thumb is abducted and rotated so that the thumb pad faces the
  1.  ;;           finger pads
  1.  ;;    ___ There is a gap of more than two inches (5.1 cm.) between the thumb
  1.  ;;        pad and the fingers, with the thumb attempting to oppose the fingers.
  1.  ;;    ___ There is a gap of two inches (5.1 cm.) or less between the thumb
  1.  ;;        pad and the fingers, with the thumb attempting to oppose the  fingers.
  1.  ;;
  1.  ;; Left thumb:
  1.  ;;    ___ Carpometacarpal joint ankylosis:
  1.  ;;       ___ In extension  ___ In full flexion  ___ In rotation or angulation
  1.  ;;       ___ Thumb is abducted and rotated so that the thumb pad faces the
  1.  ;;           finger pads
  1.  ;;    ___ Interphalangeal joint ankylosis:
  1.  ;;       ___ In extension  ___ In full flexion  ___ In rotation or angulation
  1.  ;;       ___ Thumb is abducted and rotated so that the thumb pad faces the
  1.  ;;           finger pads
  1.  ;;    ___ There is a gap of more than two inches (5.1 cm.) between the thumb
  1.  ;;        pad and the fingers, with the thumb attempting to oppose the fingers.
  1.  ;;    ___ There is a gap of two inches (5.1 cm.) or less between the thumb
  1.  ;;        pad and the fingers, with the thumb attempting to oppose the  fingers.
  1.  ;;
  1.  ;; Right:
  1.  ;;     ___ Index finger   ___ Long finger   ___ Ring finger   ___ Little finger
  1.  ;;         ___ Metacarpophalangeal joint ankylosis:
  1.  ;;            ___ In extension   ___ In full flexion
  1.  ;;            ___ In rotation or angulation
  1.  ;;            ___ Flexed to 30 degrees
  1.  ;;         ___ Proximal interphalangeal joint ankylosis:
  1.  ;;            ___ In extension   ___ In full flexion
  1.  ;;            ___ In rotation or angulation
  1.  ;;            ___ Flexed to 30 degrees
  1.  ;;         ___ There is a gap of more than two inches (5.1 cm.) between the
  1.  ;;             fingertip(s) and the proximal transverse crease of the palm,
  1.  ;;             with the finger(s) flexed to the extent possible.
  1.  ;;         ___ There is a gap of two inches (5.1 cm.) or less between the
  1.  ;;             fingertip(s) and the proximal transverse crease of the palm,
  1.  ;;             with the finger(s) flexed to the extent possible.
  1.  ;;^TOF^
  1.  ;; Left: 
  1.  ;;     ___ Index finger   ___ Long finger   ___ Ring finger   ___ Little finger
  1.  ;;         ___ Metacarpophalangeal joint ankylosis:
  1.  ;;            ___ In extension   ___ In full flexion
  1.  ;;            ___ In rotation or angulation
  1.  ;;            ___ Flexed to 30 degrees
  1.  ;;         ___ Proximal interphalangeal joint ankylosis:
  1.  ;;            ___ In extension   ___ In full flexion
  1.  ;;            ___ In rotation or angulation
  1.  ;;            ___ Flexed to 30 degrees
  1.  ;;         ___ There is a gap of more than two inches (5.1 cm.) between the
  1.  ;;             fingertip(s) and the proximal transverse crease of the palm,
  1.  ;;             with the finger(s) flexed to the extent possible.
  1.  ;;         ___ There is a gap of two inches (5.1 cm.) or less between the 
  1.  ;;             fingertip(s) and the proximal transverse crease of the palm,
  1.  ;;             with the finger(s) flexed to the extent possible.
  1.  ;;
  1.  ;; b. If there is ankylosis of more than one finger, provide details using
  1.  ;; above descriptions: ________________________________________________________
  1.  ;;
  1.  ;; c. Does the ankylosis condition result in limitation of motion of other
  1.  ;; digits or interference with overall function of the hand?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe: __________________________________________________________
  1.  ;; 
  1.  ;; 10. 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 conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): __________________________________________
  1.  ;;
  1.  ;; 11. Assistive devices and remaining function of the extremities
  1.  ;; a. Does the Veteran use any assistive devices?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, identify assistive devices used (check all that apply and indicate
  1.  ;; frequency):
  1.  ;;    ___ Brace(s)
  1.  ;;        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.  ;; 12. Remaining effective function of the extremities
  1.  ;; Due to the Veteran's hand, finger or thumb conditions, is there functional
  1.  ;; impairment of an extremity such that no effective function remains other
  1.  ;; than that which would be equally well served by an amputation with
  1.  ;; prosthesis? (Functions of the upper extremity include grasping,
  1.  ;; manipulation, etc., while functions for the lower extremity include
  1.  ;; 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 upper    ___ Left upper
  1.  ;;    For each checked extremity, identify the condition causing loss of function,
  1.  ;;    describe loss of effective function and provide specific examples (brief
  1.  ;;    summary): _______________________________________________________________
  1.  ;;
  1.  ;; 13.  Diagnostic Testing
  1.  ;; The diagnosis of arthritis must be confirmed by imaging studies. Once
  1.  ;; arthritis has been documented, no further imaging studies are required by
  1.  ;; VA, even if arthritis has worsened.
  1.  ;; a. Have imaging studies of the hands been performed and are the results 
  1.  ;; available?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, are there abnormal findings?
  1.  ;; ___ Yes   ___ No
  1.  ;;    If yes, indicate findings:
  1.  ;;       ___ Degenerative or traumatic arthritis
  1.  ;;           Hand: ___ Right   ___ Left   ___ Both
  1.  ;;           Is degenerative or traumatic arthritis documented in multiple
  1.  ;;           joints of the same hand, including thumb and fingers?
  1.  ;;           ___ Yes   ___ No
  1.  ;;           If yes, indicate hand: ___ Right   ___ Left   ___ Both
  1.  ;;       ___ Other.  Describe: ________________________________________________
  1.  ;;           Hand: ___ 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 summary):
  1.  ;; ____________________________________________________________________________
  1.  ;;^TOF^
  1.  ;; 14. Functional impact
  1.  ;; Do the Veteran's hand, thumb, or finger conditions impact his or her
  1.  ;; ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe the impact of each of the Veteran's hand, thumb and/or 
  1.  ;; finger conditions, providing one or more examples: __________________________
  1.  ;;
  1.  ;; 15. Remarks, if any: _______________________________________________________
  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