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^
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQHP3 4109 printed Dec 13, 2024@01:46:44 Page 2
DVBCQHP3 ;;ALB-CIOFO/ECF - HIP AND THIGH CONDITIONS QUESTIONNAIRE ; 5/15/2011
+1 ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;;
+2 ;; 13. Assistive devices
+3 ;; a. Does the Veteran use any assistive device(s) as a normal mode of
+4 ;; locomotion, although occasional locomotion by other methods may be possible?
+5 ;; ___ Yes ___ No
+6 ;; If yes, identify assistive device(s) used (check all that apply and indicate
+7 ;; frequency):
+8 ;;
+9 ;; ___ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
+10 ;; ___ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
+11 ;; ___ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
+12 ;; ___ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
+13 ;; ___ Walker Frequency of use: __ Occasional __ Regular __ Constant
+14 ;; ___ Other: _______________________________________________________________
+15 ;; Frequency of use: __ Occasional __ Regular __ Constant
+16 ;;
+17 ;; b. If the Veteran uses any assistive devices, specify the condition and
+18 ;; identify the assistive device used for each condition: _____________________
+19 ;; ____________________________________________________________________________
+20 ;;
+21 ;; 14. Remaining effective function of the extremities
+22 ;; Due to the Veteran's hip and/or thigh condition(s), is there functional
+23 ;; impairment of an extremity such that no effective function remains other
+24 ;; than that which would be equally well served by an amputation with
+25 ;; prosthesis? (Functions of the upper extremity include grasping,
+26 ;; manipulation, etc., while functions for the lower extremity include
+27 ;; balance and propulsion, etc.)
+28 ;; ___ Yes, functioning is so diminished that amputation with prosthesis
+29 ;; would equally serve the Veteran.
+30 ;; ___ No
+31 ;; If yes, indicate extremities for which this applies:
+32 ;; ___ Right lower ___ Left lower
+33 ;; For each checked extremity, identify the condition causing loss of
+34 ;; function, describe loss of effective function and provide specific
+35 ;; examples (brief summary): _______________________________________________
+36 ;;
+37 ;; 15. Diagnostic Testing
+38 ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
+39 ;; arthritis must be confirmed by imaging studies. Once such arthritis has
+40 ;; been documented, no further imaging studies are indicated, even if
+41 ;; arthritis has worsened.
+42 ;;
+43 ;; a. Have imaging studies of the hip been performed and are the results
+44 ;; available?
+45 ;; ___ Yes ___ No
+46 ;; If yes, is degenerative or traumatic arthritis documented?
+47 ;; ___ Yes ___ No
+48 ;; If yes, indicate hip: ____ Right ____ Left ____ Both
+49 ;;
+50 ;; b. Are there any other significant diagnostic test findings and/or results?
+51 ;; ___ Yes ___ No
+52 ;; If yes, provide type of test or procedure, date and results (brief
+53 ;; summary): _______________________________________________________________
+54 ;;
+55 ;; 16. Functional impact
+56 ;; Does the Veteran's hip and/or thigh condition impact his or her ability to
+57 ;; work?
+58 ;; ___ Yes ___ No
+59 ;; If yes, describe the impact of each of the Veteran's hip and/or thigh
+60 ;; conditions providing one or more examples: _________________________________
+61 ;; ____________________________________________________________________________
+62 ;;
+63 ;; 17. Remarks, if any: _______________________________________________________
+64 ;;
+65 ;; Physician signature: ____________________________________ Date: ____________
+66 ;;
+67 ;; Physician printed name: ____________________________________________________
+68 ;;
+69 ;; Medical license #: _________________________________________________________
+70 ;;
+71 ;; Physician address: _________________________________________________________
+72 ;;
+73 ;; Phone: _____________________________ FAX: ______________________________
+74 ;;
+75 ;; NOTE: VA may request additional medical information, including additional
+76 ;; examinations if necessary to complete VA's review of the Veteran's
+77 ;; application.
+78 ;;^END^
+79 QUIT
