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Routine: DVBCQHP2

DVBCQHP2.m

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  1. DVBCQHP2 ;;ALB-CIOFO/ECF -  HIP AND THIGH CONDITIONS QUESTIONNAIRE ; 5/15/2011
  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 hip and/or thigh condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide only diagnoses that pertain to hip/thigh conditions:
  1.  ;; Diagnosis #1: _____________________
  1.  ;; ICD code:  ____________________
  1.  ;; Date of diagnosis: ________________
  1.  ;; Side affected: ____ Right   ____ Left   ____ Both
  1.  ;;
  1.  ;; Diagnosis #2: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;; Side affected: ____ Right   ____ Left   ____ Both
  1.  ;;
  1.  ;; Diagnosis #3: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;; Side affected: ____ Right   ____ Left   ____ Both
  1.  ;;
  1.  ;; If there are additional diagnoses pertaining to hip/thigh conditions, list
  1.  ;; using above format:_________________________________________________________
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;; Describe the history (including onset and course) of the Veteran's current
  1.  ;; hip/thigh condition(s) (brief summary):_____________________________________
  1.  ;;
  1.  ;; 3. Flare-ups
  1.  ;; Does the Veteran report that flare-ups impact the function of the hip
  1.  ;; and/or thigh?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, document the Veteran's description of the impact of flare-ups in
  1.  ;; his or her own words: ______________________________________________________
  1.  ;;
  1.  ;; 4. Initial range of motion (ROM) measurements
  1.  ;; Measure ROM with a goniometer, rounding each measurement to the nearest
  1.  ;; 5 degrees. During the measurements, document the point at which painful
  1.  ;; motion begins, evidenced by visible behavior such as facial expression,
  1.  ;; wincing, etc. Report initial measurements below.
  1.  ;;
  1.  ;; Following the initial assessment of ROM, perform repetitive use testing.
  1.  ;; For VA purposes, repetitive use testing must be included in all joint
  1.  ;; exams. The VA has determined that 3 repetitions of ROM (at a minimum)
  1.  ;; can serve as a representative test of the effect of repetitive use. After
  1.  ;; the initial measurement, reassess ROM after 3 repetitions. Report
  1.  ;; post-test measurements in section 5.
  1.  ;;
  1.  ;; a. Right hip flexion
  1.  ;; Select where flexion ends (normal endpoint is 125 degrees):
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45 
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90   __95
  1.  ;; __100  __105  __110  __115  __120  __125 or greater
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;; ____ No objective evidence of painful motion
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45 
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90   __95
  1.  ;; __100  __105  __110  __115  __120  __125 or greater
  1.  ;;
  1.  ;; b. Right hip extension
  1.  ;; Select where extension ends:
  1.  ;; ___ 0  ___ 5   ___ Greater than 5
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;; ___ No objective evidence of painful motion
  1.  ;; ___ 0  ___ 5   ___ Greater than 5
  1.  ;;
  1.  ;; Is abduction lost beyond 10 degrees?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; Is adduction limited such that the Veteran cannot cross legs?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; Is rotation limited such that the Veteran cannot toe-out more than 15 degrees?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; c. Left hip flexion
  1.  ;; Select where flexion ends (normal endpoint is 125 degrees):
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45 
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90   __95
  1.  ;; __100  __105  __110  __115  __120  __125 or greater
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;; ____ No objective evidence of painful motion
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45 
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90   __95
  1.  ;; __100  __105  __110  __115  __120  __125 or greater
  1.  ;;
  1.  ;; d. Left hip extension
  1.  ;; Select where extension ends:
  1.  ;; ___ 0  ___ 5   ___ Greater than 5
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;; ___ No objective evidence of painful motion
  1.  ;; ___ 0  ___ 5   ___ Greater than 5
  1.  ;;
  1.  ;; Is abduction lost beyond 10 degrees?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; Is adduction limited such that the Veteran cannot cross legs?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; Is rotation limited such that the Veteran cannot toe-out more than 15 degrees?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; e. If ROM does not conform to the normal range of motion identified above
  1.  ;; but is normal for this Veteran (for reasons other than a hip condition,
  1.  ;; such as age, body habitus, neurologic disease), explain: ___________________
  1.  ;;
  1.  ;; 5. ROM measurements after repetitive use testing
  1.  ;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
  1.  ;; ___ Yes   ___ No    If unable, provide reason: ______________________________
  1.  ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
  1.  ;; If Veteran is able to perform repetitive-use testing, measure and report
  1.  ;; ROM after a minimum of 3 repetitions.
  1.  ;;
  1.  ;; b. Right hip post-test ROM
  1.  ;; Select where post-test flexion ends:
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45 
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90   __95
  1.  ;; __100  __105  __110  __115  __120  __125 or greater
  1.  ;;
  1.  ;; Select where post-test extension ends:
  1.  ;; ____ 0  ____ 5 or greater
  1.  ;;
  1.  ;; Is post-test abduction lost beyond 10 degrees?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; Is post-test adduction limited such that the Veteran cannot cross legs?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; Is post-test rotation limited such that the Veteran cannot toe-out more
  1.  ;; than 15 degrees?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; c. Left hip post-test ROM
  1.  ;; Select where post-test flexion ends:
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45 
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90   __95
  1.  ;; __100  __105  __110  __115  __120  __125 or greater
  1.  ;;
  1.  ;; Select where post-test extension ends:
  1.  ;; ___ 0  ___ 5 or greater
  1.  ;;
  1.  ;; Is post-test abduction lost beyond 10 degrees?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; Is post-test adduction limited such that the Veteran cannot cross legs?
  1.  ;; ___ Yes   ___ No
  1.  ;;^TOF^
  1.  ;; Is post-test rotation limited such that the Veteran cannot toe-out more
  1.  ;; than 15 degrees?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; 6. Functional loss and additional limitation in ROM
  1.  ;; The following section addresses reasons for functional loss, if present,
  1.  ;; and additional loss of ROM after repetitive-use testing, if present. The
  1.  ;; VA defines functional loss as the inability to perform normal working
  1.  ;; movements of the body with normal excursion, strength, speed, coordination
  1.  ;; and/or endurance.
  1.  ;;
  1.  ;; a. Does the Veteran have additional limitation in ROM of the hip and thigh
  1.  ;; following repetitive-use testing?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; b. Does the Veteran have any functional loss and/or functional impairment
  1.  ;; of the hip and thigh?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; c. If the Veteran has functional loss, functional impairment and/or
  1.  ;; additional limitation of ROM of the hip and thigh after repetitive use,
  1.  ;; indicate the contributing factors of disability below (check all that
  1.  ;; apply and indicate side affected):
  1.  ;; ___ No functional loss for right lower extremity
  1.  ;; ___ No functional loss for left lower extremity
  1.  ;;     ___ Less movement than normal          ___ Right   ___ Left   ___ Both
  1.  ;;     ___ More movement than normal          ___ Right   ___ Left   ___ Both
  1.  ;;     ___ Weakened movement                  ___ Right   ___ Left   ___ Both
  1.  ;;     ___ Excess fatigability                ___ Right   ___ Left   ___ Both
  1.  ;;     ___ Incoordination, impaired ability   ___ Right   ___ Left   ___ Both
  1.  ;;         to execute skilled movement smoothly
  1.  ;;     ___ Pain on movement                   ___ Right   ___ Left   ____Both
  1.  ;;     ___ Swelling                           ___ Right   ___ Left   ___ Both
  1.  ;;     ___ Deformity                          ___ Right   ___ Left   ___ Both
  1.  ;;     ___ Atrophy of disuse                  ___ Right   ___ Left   ___ Both
  1.  ;;     ___ Instability of station             ___ Right   ___ Left   ___ Both
  1.  ;;     ___ Disturbance of locomotion          ___ Right   ___ Left   ___ Both
  1.  ;;     ___ Interference with sitting,         ___ Right   ___ Left   ___ Both
  1.  ;;         standing and or weight-bearing
  1.  ;;
  1.  ;; 7. Pain (pain on palpation)
  1.  ;; Does the Veteran have localized tenderness or pain to palpation for
  1.  ;; joints/soft tissue of either hip?
  1.  ;; ___ Yes   ___ No
  1.  ;;    If yes, side affected: ____ Right   ____ Left   ____ Both
  1.  ;;^TOF^
  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.  ;;    Hip flexion:
  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.  ;;    Hip abduction:
  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.  ;;    Hip extension:
  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.  ;;
  1.  ;; 9. Ankylosis
  1.  ;; Does the Veteran have ankylosis of either hip joint?
  1.  ;; ____ Yes    ____ No
  1.  ;; If yes, indicate severity and side affected:
  1.  ;;    ___ Favorable, in flexion at an angle between 20 and 40 degrees, and
  1.  ;;        slight adduction or abduction
  1.  ;;           ___ Right  ___ Left   ___ Both
  1.  ;;    ___ Intermediate, between favorable and unfavorable
  1.  ;;            ___ Right  ___ Left   ___ Both
  1.  ;;    ___ Unfavorable, extremely unfavorable ankylosis, foot not reaching
  1.  ;;        ground, crutches needed
  1.  ;;        ___ Right  ___ Left   ___ Both
  1.  ;;
  1.  ;; 10. Additional conditions
  1.  ;; Does the Veteran have malunion or nonunion of femur, flail hip joint or leg
  1.  ;; length discrepancy?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate condition and complete the appropriate sections below.
  1.  ;;
  1.  ;; a. ___ Malunion or nonunion of the femur
  1.  ;; If checked, indicate severity and side affected:
  1.  ;;    ___ Malunion with slight hip disability          ___Right  ___Left   ___Both
  1.  ;;    ___ Malunion with moderate hip disability        ___Right  ___Left   ___Both
  1.  ;;    ___ Malunion with marked hip disability          ___Right  ___Left   ___Both
  1.  ;;    ___ Fracture of surgical neck with false joint   ___Right  ___Left  ___ Both
  1.  ;;    ___ Fracture of shaft or neck (anatomical),      ___Right  ___Left  ___ Both
  1.  ;;        resulting in nonunion without loose motion;
  1.  ;;        weight-bearing preserved with aid of a brace
  1.  ;;    ___ Fracture of shaft or neck (anatomical), with ___Right  ___Left  ___ Both
  1.  ;;        nonunion with loose motion (spiral or oblique fracture)
  1.  ;;
  1.  ;;    NOTE: If impairment of the femur causes any knee disability, also
  1.  ;;    complete the Knee and Lower Leg Questionnaire.
  1.  ;;
  1.  ;; b. ___ Flail hip joint
  1.  ;; If checked, indicate hip affected:                  ___Right  ___Left   ___Both
  1.  ;;
  1.  ;; c. ____ Leg length discrepancy (shortening of any bones of the lower extremity)
  1.  ;; If checked, provide length of each lower extremity in inches (to the
  1.  ;; nearest 1/4 inch) or centimeters, measuring from the anterior superior
  1.  ;; iliac spine to the internal malleolus of the tibia.
  1.  ;;    Measurements: Right leg: _________    ___ cm   ___ inches
  1.  ;;                  Left leg:  _________    ___ cm   ___ inches
  1.  ;;
  1.  ;; 11. Joint replacement and other surgical procedures
  1.  ;; a. Has the Veteran had a total hip joint replacement?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side and severity of residuals.
  1.  ;;    ___ Right hip
  1.  ;;        Date of surgery: ___________________
  1.  ;;        Residuals:
  1.  ;;        ___ None
  1.  ;;        ___ Intermediate degrees of residual weakness, pain and/or
  1.  ;;            limitation of motion
  1.  ;;        ___ Chronic residuals consisting of severe painful motion
  1.  ;;            and/or weakness
  1.  ;;        ___ Other, describe: _____________
  1.  ;;    ___ Left hip
  1.  ;;        Date of surgery: ___________________
  1.  ;;        Residuals:
  1.  ;;        ___ None
  1.  ;;        ___ Intermediate degrees of residual weakness, pain or limitation
  1.  ;;            of motion
  1.  ;;        ___ Chronic residuals consisting of severe painful motion or
  1.  ;;            weakness
  1.  ;;        ___ Other, describe: _____________
  1.  ;;
  1.  ;; b. Has the Veteran had arthroscopic or other hip surgery?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;    Date and type of surgery: _______________________________________________
  1.  ;;
  1.  ;; c. Does the Veteran have any residual signs and/or symptoms due to
  1.  ;; arthroscopic or other hip surgery?
  1.  ;; ____ Yes    ____ No
  1.  ;; If yes, indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;    If yes, describe residuals: _____________________________________________
  1.  ;;^TOF^
  1.  ;; 12. 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.  Q