©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
DVBCQHP3 ;;ALB-CIOFO/ECF - HIP AND THIGH CONDITIONS QUESTIONNAIRE ; 5/15/2011
;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
;
TXT ;
;;
;; 13. Assistive devices
;; a. Does the Veteran use any assistive device(s) as a normal mode of
;; locomotion, although occasional locomotion by other methods may be possible?
;; ___ Yes ___ No
;; If yes, identify assistive device(s) used (check all that apply and indicate
;; frequency):
;;
;; ___ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
;; ___ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
;; ___ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
;; ___ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
;; ___ Walker 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: _____________________
;; ____________________________________________________________________________
;;
;; 14. Remaining effective function of the extremities
;; Due to the Veteran's hip and/or thigh condition(s), 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 lower ___ Left lower
;; For each checked extremity, identify the condition causing loss of
;; function, describe loss of effective function and provide specific
;; examples (brief summary): _______________________________________________
;;
;; 15. Diagnostic Testing
;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
;; arthritis must be confirmed by imaging studies. Once such arthritis has
;; been documented, no further imaging studies are indicated, even if
;; arthritis has worsened.
;;
;; a. Have imaging studies of the hip been performed and are the results
;; available?
;; ___ Yes ___ No
;; If yes, is degenerative or traumatic arthritis documented?
;; ___ Yes ___ No
;; If yes, indicate hip: ____ 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): _______________________________________________________________
;;
;; 16. Functional impact
;; Does the Veteran's hip and/or thigh condition impact his or her ability to
;; work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's hip and/or thigh
;; conditions providing one or more examples: _________________________________
;; ____________________________________________________________________________
;;
;; 17. 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^
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