DVBCQHP2 ;;ALB-CIOFO/ECF - HIP AND THIGH CONDITIONS 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 hip and/or thigh condition?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to hip/thigh 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 pertaining to hip/thigh conditions, list
;; using above format:_________________________________________________________
;;
;; 2. Medical history
;; Describe the history (including onset and course) of the Veteran's current
;; hip/thigh condition(s) (brief summary):_____________________________________
;;
;; 3. Flare-ups
;; Does the Veteran report that flare-ups impact the function of the hip
;; and/or thigh?
;; ___ 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. Right hip flexion
;; Select where flexion ends (normal endpoint is 125 degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
;; __100 __105 __110 __115 __120 __125 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ____ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
;; __100 __105 __110 __115 __120 __125 or greater
;;
;; b. Right hip extension
;; Select where extension ends:
;; ___ 0 ___ 5 ___ Greater than 5
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___ 0 ___ 5 ___ Greater than 5
;;
;; Is abduction lost beyond 10 degrees?
;; ___ Yes ___ No
;;
;; Is adduction limited such that the Veteran cannot cross legs?
;; ___ Yes ___ No
;;
;; Is rotation limited such that the Veteran cannot toe-out more than 15 degrees?
;; ___ Yes ___ No
;;
;; c. Left hip flexion
;; Select where flexion ends (normal endpoint is 125 degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
;; __100 __105 __110 __115 __120 __125 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ____ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
;; __100 __105 __110 __115 __120 __125 or greater
;;
;; d. Left hip extension
;; Select where extension ends:
;; ___ 0 ___ 5 ___ Greater than 5
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___ 0 ___ 5 ___ Greater than 5
;;
;; Is abduction lost beyond 10 degrees?
;; ___ Yes ___ No
;;
;; Is adduction limited such that the Veteran cannot cross legs?
;; ___ Yes ___ No
;;
;; Is rotation limited such that the Veteran cannot toe-out more than 15 degrees?
;; ___ Yes ___ No
;;
;; 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 hip condition,
;; such as age, body habitus, neurologic disease), explain: ___________________
;;
;; 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. Right hip post-test ROM
;; Select where post-test flexion ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
;; __100 __105 __110 __115 __120 __125 or greater
;;
;; Select where post-test extension ends:
;; ____ 0 ____ 5 or greater
;;
;; Is post-test abduction lost beyond 10 degrees?
;; ___ Yes ___ No
;;
;; Is post-test adduction limited such that the Veteran cannot cross legs?
;; ___ Yes ___ No
;;
;; Is post-test rotation limited such that the Veteran cannot toe-out more
;; than 15 degrees?
;; ___ Yes ___ No
;;
;; c. Left hip post-test ROM
;; Select where post-test flexion ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
;; __100 __105 __110 __115 __120 __125 or greater
;;
;; Select where post-test extension ends:
;; ___ 0 ___ 5 or greater
;;
;; Is post-test abduction lost beyond 10 degrees?
;; ___ Yes ___ No
;;
;; Is post-test adduction limited such that the Veteran cannot cross legs?
;; ___ Yes ___ No
;;^TOF^
;; Is post-test rotation limited such that the Veteran cannot toe-out more
;; than 15 degrees?
;; ___ Yes ___ No
;;
;; 6. Functional loss and additional limitation in 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 additional limitation in ROM of the hip and thigh
;; following repetitive-use testing?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have any functional loss and/or functional impairment
;; of the hip and thigh?
;; ___ Yes ___ No
;;
;; c. If the Veteran has functional loss, functional impairment and/or
;; additional limitation of ROM of the hip and thigh after repetitive use,
;; indicate the contributing factors of disability below (check all that
;; apply and indicate side affected):
;; ___ No functional loss for right lower extremity
;; ___ No functional loss for left lower extremity
;; ___ Less movement than normal ___ Right ___ Left ___ Both
;; ___ More movement than normal ___ Right ___ Left ___ Both
;; ___ Weakened movement ___ Right ___ Left ___ Both
;; ___ Excess fatigability ___ Right ___ Left ___ Both
;; ___ Incoordination, impaired ability ___ Right ___ Left ___ Both
;; to execute skilled movement smoothly
;; ___ Pain on movement ___ Right ___ Left ____Both
;; ___ Swelling ___ Right ___ Left ___ Both
;; ___ Deformity ___ Right ___ Left ___ Both
;; ___ Atrophy of disuse ___ Right ___ Left ___ Both
;; ___ Instability of station ___ Right ___ Left ___ Both
;; ___ Disturbance of locomotion ___ Right ___ Left ___ Both
;; ___ Interference with sitting, ___ Right ___ Left ___ Both
;; standing and or weight-bearing
;;
;; 7. Pain (pain on palpation)
;; Does the Veteran have localized tenderness or pain to palpation for
;; joints/soft tissue of either hip?
;; ___ Yes ___ No
;; If yes, side affected: ____ Right ____ Left ____ Both
;;^TOF^
;; 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
;; Hip flexion:
;; 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
;; Hip abduction:
;; 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
;; Hip extension:
;; 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
;;
;; 9. Ankylosis
;; Does the Veteran have ankylosis of either hip joint?
;; ____ Yes ____ No
;; If yes, indicate severity and side affected:
;; ___ Favorable, in flexion at an angle between 20 and 40 degrees, and
;; slight adduction or abduction
;; ___ Right ___ Left ___ Both
;; ___ Intermediate, between favorable and unfavorable
;; ___ Right ___ Left ___ Both
;; ___ Unfavorable, extremely unfavorable ankylosis, foot not reaching
;; ground, crutches needed
;; ___ Right ___ Left ___ Both
;;
;; 10. Additional conditions
;; Does the Veteran have malunion or nonunion of femur, flail hip joint or leg
;; length discrepancy?
;; ___ Yes ___ No
;; If yes, indicate condition and complete the appropriate sections below.
;;
;; a. ___ Malunion or nonunion of the femur
;; If checked, indicate severity and side affected:
;; ___ Malunion with slight hip disability ___Right ___Left ___Both
;; ___ Malunion with moderate hip disability ___Right ___Left ___Both
;; ___ Malunion with marked hip disability ___Right ___Left ___Both
;; ___ Fracture of surgical neck with false joint ___Right ___Left ___ Both
;; ___ Fracture of shaft or neck (anatomical), ___Right ___Left ___ Both
;; resulting in nonunion without loose motion;
;; weight-bearing preserved with aid of a brace
;; ___ Fracture of shaft or neck (anatomical), with ___Right ___Left ___ Both
;; nonunion with loose motion (spiral or oblique fracture)
;;
;; NOTE: If impairment of the femur causes any knee disability, also
;; complete the Knee and Lower Leg Questionnaire.
;;
;; b. ___ Flail hip joint
;; If checked, indicate hip affected: ___Right ___Left ___Both
;;
;; c. ____ Leg length discrepancy (shortening of any bones of the lower extremity)
;; If checked, provide length of each lower extremity in inches (to the
;; nearest 1/4 inch) or centimeters, measuring from the anterior superior
;; iliac spine to the internal malleolus of the tibia.
;; Measurements: Right leg: _________ ___ cm ___ inches
;; Left leg: _________ ___ cm ___ inches
;;
;; 11. Joint replacement and other surgical procedures
;; a. Has the Veteran had a total hip joint replacement?
;; ___ Yes ___ No
;; If yes, indicate side and severity of residuals.
;; ___ Right hip
;; Date of surgery: ___________________
;; Residuals:
;; ___ None
;; ___ Intermediate degrees of residual weakness, pain and/or
;; limitation of motion
;; ___ Chronic residuals consisting of severe painful motion
;; and/or weakness
;; ___ Other, describe: _____________
;; ___ Left hip
;; Date of surgery: ___________________
;; Residuals:
;; ___ None
;; ___ Intermediate degrees of residual weakness, pain or limitation
;; of motion
;; ___ Chronic residuals consisting of severe painful motion or
;; weakness
;; ___ Other, describe: _____________
;;
;; b. Has the Veteran had arthroscopic or other hip surgery?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; Date and type of surgery: _______________________________________________
;;
;; c. Does the Veteran have any residual signs and/or symptoms due to
;; arthroscopic or other hip surgery?
;; ____ Yes ____ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; If yes, describe residuals: _____________________________________________
;;^TOF^
;; 12. 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): __________________________________________
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQHP2 14729 printed Apr 09, 2024@20:56:35 Page 2
DVBCQHP2 ;;ALB-CIOFO/ECF - HIP AND THIGH CONDITIONS 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 hip and/or thigh condition?
+7 ;; ___ Yes ___ No
+8 ;;
+9 ;; If yes, provide only diagnoses that pertain to hip/thigh 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 pertaining to hip/thigh conditions, list
+26 ;; using above format:_________________________________________________________
+27 ;;
+28 ;; 2. Medical history
+29 ;; Describe the history (including onset and course) of the Veteran's current
+30 ;; hip/thigh condition(s) (brief summary):_____________________________________
+31 ;;
+32 ;; 3. Flare-ups
+33 ;; Does the Veteran report that flare-ups impact the function of the hip
+34 ;; and/or thigh?
+35 ;; ___ Yes ___ No
+36 ;; If yes, document the Veteran's description of the impact of flare-ups in
+37 ;; his or her own words: ______________________________________________________
+38 ;;
+39 ;; 4. Initial range of motion (ROM) measurements
+40 ;; Measure ROM with a goniometer, rounding each measurement to the nearest
+41 ;; 5 degrees. During the measurements, document the point at which painful
+42 ;; motion begins, evidenced by visible behavior such as facial expression,
+43 ;; wincing, etc. Report initial measurements below.
+44 ;;
+45 ;; Following the initial assessment of ROM, perform repetitive use testing.
+46 ;; For VA purposes, repetitive use testing must be included in all joint
+47 ;; exams. The VA has determined that 3 repetitions of ROM (at a minimum)
+48 ;; can serve as a representative test of the effect of repetitive use. After
+49 ;; the initial measurement, reassess ROM after 3 repetitions. Report
+50 ;; post-test measurements in section 5.
+51 ;;
+52 ;; a. Right hip flexion
+53 ;; Select where flexion ends (normal endpoint is 125 degrees):
+54 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+55 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
+56 ;; __100 __105 __110 __115 __120 __125 or greater
+57 ;;
+58 ;; Select where objective evidence of painful motion begins:
+59 ;; ____ No objective evidence of painful motion
+60 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+61 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
+62 ;; __100 __105 __110 __115 __120 __125 or greater
+63 ;;
+64 ;; b. Right hip extension
+65 ;; Select where extension ends:
+66 ;; ___ 0 ___ 5 ___ Greater than 5
+67 ;;
+68 ;; Select where objective evidence of painful motion begins:
+69 ;; ___ No objective evidence of painful motion
+70 ;; ___ 0 ___ 5 ___ Greater than 5
+71 ;;
+72 ;; Is abduction lost beyond 10 degrees?
+73 ;; ___ Yes ___ No
+74 ;;
+75 ;; Is adduction limited such that the Veteran cannot cross legs?
+76 ;; ___ Yes ___ No
+77 ;;
+78 ;; Is rotation limited such that the Veteran cannot toe-out more than 15 degrees?
+79 ;; ___ Yes ___ No
+80 ;;
+81 ;; c. Left hip flexion
+82 ;; Select where flexion ends (normal endpoint is 125 degrees):
+83 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+84 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
+85 ;; __100 __105 __110 __115 __120 __125 or greater
+86 ;;
+87 ;; Select where objective evidence of painful motion begins:
+88 ;; ____ No objective evidence of painful motion
+89 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+90 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
+91 ;; __100 __105 __110 __115 __120 __125 or greater
+92 ;;
+93 ;; d. Left hip extension
+94 ;; Select where extension ends:
+95 ;; ___ 0 ___ 5 ___ Greater than 5
+96 ;;
+97 ;; Select where objective evidence of painful motion begins:
+98 ;; ___ No objective evidence of painful motion
+99 ;; ___ 0 ___ 5 ___ Greater than 5
+100 ;;
+101 ;; Is abduction lost beyond 10 degrees?
+102 ;; ___ Yes ___ No
+103 ;;
+104 ;; Is adduction limited such that the Veteran cannot cross legs?
+105 ;; ___ Yes ___ No
+106 ;;
+107 ;; Is rotation limited such that the Veteran cannot toe-out more than 15 degrees?
+108 ;; ___ Yes ___ No
+109 ;;
+110 ;; e. If ROM does not conform to the normal range of motion identified above
+111 ;; but is normal for this Veteran (for reasons other than a hip condition,
+112 ;; such as age, body habitus, neurologic disease), explain: ___________________
+113 ;;
+114 ;; 5. ROM measurements after repetitive use testing
+115 ;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
+116 ;; ___ Yes ___ No If unable, provide reason: ______________________________
+117 ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
+118 ;; If Veteran is able to perform repetitive-use testing, measure and report
+119 ;; ROM after a minimum of 3 repetitions.
+120 ;;
+121 ;; b. Right hip post-test ROM
+122 ;; Select where post-test flexion ends:
+123 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+124 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
+125 ;; __100 __105 __110 __115 __120 __125 or greater
+126 ;;
+127 ;; Select where post-test extension ends:
+128 ;; ____ 0 ____ 5 or greater
+129 ;;
+130 ;; Is post-test abduction lost beyond 10 degrees?
+131 ;; ___ Yes ___ No
+132 ;;
+133 ;; Is post-test adduction limited such that the Veteran cannot cross legs?
+134 ;; ___ Yes ___ No
+135 ;;
+136 ;; Is post-test rotation limited such that the Veteran cannot toe-out more
+137 ;; than 15 degrees?
+138 ;; ___ Yes ___ No
+139 ;;
+140 ;; c. Left hip post-test ROM
+141 ;; Select where post-test flexion ends:
+142 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+143 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90 __95
+144 ;; __100 __105 __110 __115 __120 __125 or greater
+145 ;;
+146 ;; Select where post-test extension ends:
+147 ;; ___ 0 ___ 5 or greater
+148 ;;
+149 ;; Is post-test abduction lost beyond 10 degrees?
+150 ;; ___ Yes ___ No
+151 ;;
+152 ;; Is post-test adduction limited such that the Veteran cannot cross legs?
+153 ;; ___ Yes ___ No
+154 ;;^TOF^
+155 ;; Is post-test rotation limited such that the Veteran cannot toe-out more
+156 ;; than 15 degrees?
+157 ;; ___ Yes ___ No
+158 ;;
+159 ;; 6. Functional loss and additional limitation in ROM
+160 ;; The following section addresses reasons for functional loss, if present,
+161 ;; and additional loss of ROM after repetitive-use testing, if present. The
+162 ;; VA defines functional loss as the inability to perform normal working
+163 ;; movements of the body with normal excursion, strength, speed, coordination
+164 ;; and/or endurance.
+165 ;;
+166 ;; a. Does the Veteran have additional limitation in ROM of the hip and thigh
+167 ;; following repetitive-use testing?
+168 ;; ___ Yes ___ No
+169 ;;
+170 ;; b. Does the Veteran have any functional loss and/or functional impairment
+171 ;; of the hip and thigh?
+172 ;; ___ Yes ___ No
+173 ;;
+174 ;; c. If the Veteran has functional loss, functional impairment and/or
+175 ;; additional limitation of ROM of the hip and thigh after repetitive use,
+176 ;; indicate the contributing factors of disability below (check all that
+177 ;; apply and indicate side affected):
+178 ;; ___ No functional loss for right lower extremity
+179 ;; ___ No functional loss for left lower extremity
+180 ;; ___ Less movement than normal ___ Right ___ Left ___ Both
+181 ;; ___ More movement than normal ___ Right ___ Left ___ Both
+182 ;; ___ Weakened movement ___ Right ___ Left ___ Both
+183 ;; ___ Excess fatigability ___ Right ___ Left ___ Both
+184 ;; ___ Incoordination, impaired ability ___ Right ___ Left ___ Both
+185 ;; to execute skilled movement smoothly
+186 ;; ___ Pain on movement ___ Right ___ Left ____Both
+187 ;; ___ Swelling ___ Right ___ Left ___ Both
+188 ;; ___ Deformity ___ Right ___ Left ___ Both
+189 ;; ___ Atrophy of disuse ___ Right ___ Left ___ Both
+190 ;; ___ Instability of station ___ Right ___ Left ___ Both
+191 ;; ___ Disturbance of locomotion ___ Right ___ Left ___ Both
+192 ;; ___ Interference with sitting, ___ Right ___ Left ___ Both
+193 ;; standing and or weight-bearing
+194 ;;
+195 ;; 7. Pain (pain on palpation)
+196 ;; Does the Veteran have localized tenderness or pain to palpation for
+197 ;; joints/soft tissue of either hip?
+198 ;; ___ Yes ___ No
+199 ;; If yes, side affected: ____ Right ____ Left ____ Both
+200 ;;^TOF^
+201 ;; 8. Muscle strength testing
+202 ;; Rate strength according to the following scale:
+203 ;; 0/5 No muscle movement
+204 ;; 1/5 Palpable or visible muscle contraction, but no joint movement
+205 ;; 2/5 Active movement with gravity eliminated
+206 ;; 3/5 Active movement against gravity
+207 ;; 4/5 Active movement against some resistance
+208 ;; 5/5 Normal strength
+209 ;; Hip flexion:
+210 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+211 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+212 ;; Hip abduction:
+213 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+214 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+215 ;; Hip extension:
+216 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+217 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+218 ;;
+219 ;; 9. Ankylosis
+220 ;; Does the Veteran have ankylosis of either hip joint?
+221 ;; ____ Yes ____ No
+222 ;; If yes, indicate severity and side affected:
+223 ;; ___ Favorable, in flexion at an angle between 20 and 40 degrees, and
+224 ;; slight adduction or abduction
+225 ;; ___ Right ___ Left ___ Both
+226 ;; ___ Intermediate, between favorable and unfavorable
+227 ;; ___ Right ___ Left ___ Both
+228 ;; ___ Unfavorable, extremely unfavorable ankylosis, foot not reaching
+229 ;; ground, crutches needed
+230 ;; ___ Right ___ Left ___ Both
+231 ;;
+232 ;; 10. Additional conditions
+233 ;; Does the Veteran have malunion or nonunion of femur, flail hip joint or leg
+234 ;; length discrepancy?
+235 ;; ___ Yes ___ No
+236 ;; If yes, indicate condition and complete the appropriate sections below.
+237 ;;
+238 ;; a. ___ Malunion or nonunion of the femur
+239 ;; If checked, indicate severity and side affected:
+240 ;; ___ Malunion with slight hip disability ___Right ___Left ___Both
+241 ;; ___ Malunion with moderate hip disability ___Right ___Left ___Both
+242 ;; ___ Malunion with marked hip disability ___Right ___Left ___Both
+243 ;; ___ Fracture of surgical neck with false joint ___Right ___Left ___ Both
+244 ;; ___ Fracture of shaft or neck (anatomical), ___Right ___Left ___ Both
+245 ;; resulting in nonunion without loose motion;
+246 ;; weight-bearing preserved with aid of a brace
+247 ;; ___ Fracture of shaft or neck (anatomical), with ___Right ___Left ___ Both
+248 ;; nonunion with loose motion (spiral or oblique fracture)
+249 ;;
+250 ;; NOTE: If impairment of the femur causes any knee disability, also
+251 ;; complete the Knee and Lower Leg Questionnaire.
+252 ;;
+253 ;; b. ___ Flail hip joint
+254 ;; If checked, indicate hip affected: ___Right ___Left ___Both
+255 ;;
+256 ;; c. ____ Leg length discrepancy (shortening of any bones of the lower extremity)
+257 ;; If checked, provide length of each lower extremity in inches (to the
+258 ;; nearest 1/4 inch) or centimeters, measuring from the anterior superior
+259 ;; iliac spine to the internal malleolus of the tibia.
+260 ;; Measurements: Right leg: _________ ___ cm ___ inches
+261 ;; Left leg: _________ ___ cm ___ inches
+262 ;;
+263 ;; 11. Joint replacement and other surgical procedures
+264 ;; a. Has the Veteran had a total hip joint replacement?
+265 ;; ___ Yes ___ No
+266 ;; If yes, indicate side and severity of residuals.
+267 ;; ___ Right hip
+268 ;; Date of surgery: ___________________
+269 ;; Residuals:
+270 ;; ___ None
+271 ;; ___ Intermediate degrees of residual weakness, pain and/or
+272 ;; limitation of motion
+273 ;; ___ Chronic residuals consisting of severe painful motion
+274 ;; and/or weakness
+275 ;; ___ Other, describe: _____________
+276 ;; ___ Left hip
+277 ;; Date of surgery: ___________________
+278 ;; Residuals:
+279 ;; ___ None
+280 ;; ___ Intermediate degrees of residual weakness, pain or limitation
+281 ;; of motion
+282 ;; ___ Chronic residuals consisting of severe painful motion or
+283 ;; weakness
+284 ;; ___ Other, describe: _____________
+285 ;;
+286 ;; b. Has the Veteran had arthroscopic or other hip surgery?
+287 ;; ___ Yes ___ No
+288 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+289 ;; Date and type of surgery: _______________________________________________
+290 ;;
+291 ;; c. Does the Veteran have any residual signs and/or symptoms due to
+292 ;; arthroscopic or other hip surgery?
+293 ;; ____ Yes ____ No
+294 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+295 ;; If yes, describe residuals: _____________________________________________
+296 ;;^TOF^
+297 ;; 12. Other pertinent physical findings, complications, conditions, signs
+298 ;; and/or symptoms
+299 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+300 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+301 ;; section above?
+302 ;; ___ Yes ___ No
+303 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+304 ;; of all related scars greater than 39 square cm (6 square inches)?
+305 ;; ___ Yes ___ No
+306 ;; If yes, also complete a Scars Questionnaire.
+307 ;;
+308 ;; b. Does the Veteran have any other pertinent physical findings,
+309 ;; complications, conditions, signs and/or symptoms related to any conditions
+310 ;; listed in the Diagnosis section above?
+311 ;; ___ Yes ___ No
+312 ;; If yes, describe (brief summary): __________________________________________
+313 QUIT
