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Routine: DVBCQHP3

DVBCQHP3.m

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  1. DVBCQHP3 ;;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.  ;;
  1.  ;; 13. Assistive devices
  1.  ;; a. Does the Veteran use any assistive device(s) as a normal mode of
  1.  ;; locomotion, although occasional locomotion by other methods may be possible?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, identify assistive device(s) used (check all that apply and indicate
  1.  ;; frequency):
  1.  ;;
  1.  ;;   ___ Wheelchair  Frequency of use: __ Occasional   __ Regular   __ Constant
  1.  ;;   ___ Brace(s)    Frequency of use: __ Occasional   __ Regular   __ Constant
  1.  ;;   ___ Crutch(es)  Frequency of use: __ Occasional   __ Regular   __ Constant
  1.  ;;   ___ Cane(s)     Frequency of use: __ Occasional   __ Regular   __ Constant
  1.  ;;   ___ Walker      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.  ;; 14. Remaining effective function of the extremities
  1.  ;; Due to the Veteran's hip and/or thigh condition(s), 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
  1.  ;; would equally serve the Veteran.
  1.  ;; ___ No
  1.  ;;    If yes, indicate extremities for which this applies:
  1.  ;;    ___ Right lower    ___ Left lower
  1.  ;;    For each checked extremity, identify the condition causing loss of
  1.  ;;    function, describe loss of effective function and provide specific
  1.  ;;    examples (brief summary): _______________________________________________
  1.  ;;
  1.  ;; 15.  Diagnostic Testing
  1.  ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
  1.  ;; arthritis must be confirmed by imaging studies. Once such arthritis has
  1.  ;; been documented, no further imaging studies are indicated, even if
  1.  ;; arthritis has worsened.
  1.  ;;
  1.  ;; a. Have imaging studies of the hip been performed and are the results
  1.  ;; available?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, is degenerative or traumatic arthritis documented?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If yes, indicate hip: ____ 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
  1.  ;;    summary): _______________________________________________________________
  1.  ;;
  1.  ;; 16. Functional impact
  1.  ;; Does the Veteran's hip and/or thigh condition impact his or her ability to
  1.  ;; work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe the impact of each of the Veteran's hip and/or thigh
  1.  ;; conditions providing one or more examples: _________________________________
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 17. 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
  1.  ;; application.
  1.  ;;^END^
  1.  Q