DVBCQKL3 ;;ALB-CIOFO/ECF - KNEE AND LOWER LEG CONDITIONS QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;***172***;Apr 10, 1995;Build 3
;
TXT ;
;;
;; 12. Meniscal conditions and meniscal surgery
;;
;; Has the Veteran had any meniscal conditions or surgical procedures for a
;; meniscal condition?
;; ___ Yes ___ No
;; If yes, complete the following section:
;;
;; a. Does the Veteran now have or has he or she ever had a meniscus
;; (semilunar cartilage) condition?
;; ___ Yes ___ No
;; If yes, indicate severity and frequency of symptoms, and side affected:
;; ___ No symptoms ___Right ___Left ___Both
;; ___ Meniscal dislocation ___Right ___Left ___Both
;; ___ Meniscal tear ___Right ___Left ___Both
;; ___ Frequent episodes of joint "locking" ___Right ___Left ___Both
;; ___ Frequent episodes of joint pain ___Right ___Left ___Both
;; ___ Frequent episodes of joint effusion ___Right ___Left ___Both
;;
;; b. Has the Veteran had a meniscectomy?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___Right ___Left ___Both
;; Date of surgery: ___________________
;;
;; c. Does the Veteran have any residual signs and/or symptoms due to a
;; meniscectomy?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___Right ___Left ___Both
;; Describe residuals: _____________________________________________________
;;^TOF^
;; 13. Joint replacement and other surgical procedures
;;
;; a. Has the Veteran had a total knee joint replacement?
;; ___ Yes ___ No
;; If yes, indicate side and severity of residuals.
;; ___ Right knee
;; 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: ___________________________________________
;; ___ Left knee
;; 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 knee surgery not described
;; above?
;; ___ 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 knee surgery not described above?
;; ___Yes ___No
;; If yes, indicate side affected: ___Right ___Left ___Both
;; Describe residuals: _____________________________________________________
;;
;; 14. 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.
;;^TOF^
;; 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): _________________________
;;
;; 15. 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: ______________________
;;
;; ____________________________________________________________________________
;;
;; 16. Remaining effective function of the extremities
;;
;; Due to the Veteran's knee and/or lower leg 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 extremity(ies) 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): _______________________
;;^TOF^
;; 17. 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 required by VA, even if
;; arthritis has worsened.
;;
;; a. Have imaging studies of the knee been performed and are the results
;; available?
;; ___ Yes ___ No
;; If yes, is degenerative or traumatic arthritis documented?
;; ___ Yes ___ No
;; If yes, indicate knee: ___ Right ___ Left ___ Both
;;
;; b. Does the Veteran have x-ray evidence of patellar subluxation?
;; ___ Yes ___ No
;; If yes, indicate affected side(s): ___ Right ___ Left ___ Both
;;
;; c. 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):
;; ____________________________________________________________________________
;;
;; 18. Functional impact
;;
;; Does the Veteran's knee and/or lower leg condition(s) impact his or her
;; ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's knee and/or lower leg
;; conditions providing one or more examples: _________________________________
;;
;; 19. 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[HDVBCQKL3 8031 printed Apr 09, 2024@20:51:45 Page 2
DVBCQKL3 ;;ALB-CIOFO/ECF - KNEE AND LOWER LEG CONDITIONS QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;***172***;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;;
+2 ;; 12. Meniscal conditions and meniscal surgery
+3 ;;
+4 ;; Has the Veteran had any meniscal conditions or surgical procedures for a
+5 ;; meniscal condition?
+6 ;; ___ Yes ___ No
+7 ;; If yes, complete the following section:
+8 ;;
+9 ;; a. Does the Veteran now have or has he or she ever had a meniscus
+10 ;; (semilunar cartilage) condition?
+11 ;; ___ Yes ___ No
+12 ;; If yes, indicate severity and frequency of symptoms, and side affected:
+13 ;; ___ No symptoms ___Right ___Left ___Both
+14 ;; ___ Meniscal dislocation ___Right ___Left ___Both
+15 ;; ___ Meniscal tear ___Right ___Left ___Both
+16 ;; ___ Frequent episodes of joint "locking" ___Right ___Left ___Both
+17 ;; ___ Frequent episodes of joint pain ___Right ___Left ___Both
+18 ;; ___ Frequent episodes of joint effusion ___Right ___Left ___Both
+19 ;;
+20 ;; b. Has the Veteran had a meniscectomy?
+21 ;; ___ Yes ___ No
+22 ;; If yes, indicate side affected: ___Right ___Left ___Both
+23 ;; Date of surgery: ___________________
+24 ;;
+25 ;; c. Does the Veteran have any residual signs and/or symptoms due to a
+26 ;; meniscectomy?
+27 ;; ___ Yes ___ No
+28 ;; If yes, indicate side affected: ___Right ___Left ___Both
+29 ;; Describe residuals: _____________________________________________________
+30 ;;^TOF^
+31 ;; 13. Joint replacement and other surgical procedures
+32 ;;
+33 ;; a. Has the Veteran had a total knee joint replacement?
+34 ;; ___ Yes ___ No
+35 ;; If yes, indicate side and severity of residuals.
+36 ;; ___ Right knee
+37 ;; Date of surgery: ___________________
+38 ;; Residuals:
+39 ;; ___ None
+40 ;; ___ Intermediate degrees of residual weakness, pain or limitation
+41 ;; of motion
+42 ;; ___Chronic residuals consisting of severe painful motion or
+43 ;; weakness
+44 ;; ___Other, describe: ___________________________________________
+45 ;; ___ Left knee
+46 ;; Date of surgery: ___________________
+47 ;; Residuals:
+48 ;; ___None
+49 ;; ___Intermediate degrees of residual weakness, pain or limitation
+50 ;; of motion
+51 ;; ___Chronic residuals consisting of severe painful motion or
+52 ;; weakness
+53 ;; ___Other, describe: ______________________________________________
+54 ;;
+55 ;; b. Has the Veteran had arthroscopic or other knee surgery not described
+56 ;; above?
+57 ;; ___ Yes ___ No
+58 ;; If yes, indicate side affected: ___Right ___Left ___Both
+59 ;; Date and type of surgery: _____________
+60 ;;
+61 ;; c. Does the Veteran have any residual signs and/or symptoms due to
+62 ;; arthroscopic or other knee surgery not described above?
+63 ;; ___Yes ___No
+64 ;; If yes, indicate side affected: ___Right ___Left ___Both
+65 ;; Describe residuals: _____________________________________________________
+66 ;;
+67 ;; 14. Other pertinent physical findings, complications, conditions, signs
+68 ;; and/or symptoms
+69 ;;
+70 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+71 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+72 ;; section above?
+73 ;; ___ Yes ___ No
+74 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+75 ;; of all related scars greater than 39 square cm (6 square inches)?
+76 ;; ___ Yes ___ No
+77 ;; If yes, also complete a Scars Questionnaire.
+78 ;;^TOF^
+79 ;; b. Does the Veteran have any other pertinent physical findings,
+80 ;; complications, conditions, signs and/or symptoms related to any
+81 ;; conditions listed in the Diagnosis section above?
+82 ;; ___ Yes ___ No
+83 ;; If yes, describe (brief summary): _________________________
+84 ;;
+85 ;; 15. Assistive devices
+86 ;;
+87 ;; a. Does the Veteran use any assistive device(s) as a normal mode of
+88 ;; locomotion, although occasional locomotion by other methods may be possible?
+89 ;; ___ Yes ___ No
+90 ;; If yes, identify assistive device(s) used (check all that apply and indicate
+91 ;; frequency):
+92 ;;
+93 ;; ___ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
+94 ;; ___ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
+95 ;; ___ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
+96 ;; ___ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
+97 ;; ___ Walker Frequency of use: __ Occasional __ Regular __ Constant
+98 ;; ___ Other: _______________________________________________________________
+99 ;; Frequency of use: __ Occasional __ Regular __ Constant
+100 ;;
+101 ;; b. If the Veteran uses any assistive devices, specify the condition and
+102 ;; identify the assistive device used for each condition: ______________________
+103 ;;
+104 ;; ____________________________________________________________________________
+105 ;;
+106 ;; 16. Remaining effective function of the extremities
+107 ;;
+108 ;; Due to the Veteran's knee and/or lower leg condition(s), is there functional
+109 ;; impairment of an extremity such that no effective function remains other than
+110 ;; that which would be equally well served by an amputation with prosthesis?
+111 ;; (Functions of the upper extremity include grasping, manipulation, etc.,
+112 ;; while functions for the lower extremity include balance and propulsion,
+113 ;; etc.)
+114 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+115 ;; equally serve the Veteran.
+116 ;; ___ No
+117 ;; If yes, indicate extremity(ies) for which this applies:
+118 ;; ___ Right lower ___ Left lower
+119 ;; For each checked extremity, identify the condition causing loss of
+120 ;; function, describe loss of effective function and provide specific
+121 ;; examples (brief summary): _______________________
+122 ;;^TOF^
+123 ;; 17. Diagnostic testing
+124 ;;
+125 ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
+126 ;; arthritis must be confirmed by imaging studies. Once such arthritis has
+127 ;; been documented, no further imaging studies are required by VA, even if
+128 ;; arthritis has worsened.
+129 ;;
+130 ;; a. Have imaging studies of the knee been performed and are the results
+131 ;; available?
+132 ;; ___ Yes ___ No
+133 ;; If yes, is degenerative or traumatic arthritis documented?
+134 ;; ___ Yes ___ No
+135 ;; If yes, indicate knee: ___ Right ___ Left ___ Both
+136 ;;
+137 ;; b. Does the Veteran have x-ray evidence of patellar subluxation?
+138 ;; ___ Yes ___ No
+139 ;; If yes, indicate affected side(s): ___ Right ___ Left ___ Both
+140 ;;
+141 ;; c. Are there any other significant diagnostic test findings and/or results?
+142 ;; ___ Yes ___ No
+143 ;; If yes, provide type of test or procedure, date and results (brief summary):
+144 ;; ____________________________________________________________________________
+145 ;;
+146 ;; 18. Functional impact
+147 ;;
+148 ;; Does the Veteran's knee and/or lower leg condition(s) impact his or her
+149 ;; ability to work?
+150 ;; ___ Yes ___ No
+151 ;; If yes, describe the impact of each of the Veteran's knee and/or lower leg
+152 ;; conditions providing one or more examples: _________________________________
+153 ;;
+154 ;; 19. Remarks, if any: _______________________________________________________
+155 ;;
+156 ;; Physician signature: ____________________________________ Date: ____________
+157 ;;
+158 ;; Physician printed name: ____________________________________________________
+159 ;;
+160 ;; Medical license #: _________________________________________________________
+161 ;;
+162 ;; Physician address: _________________________________________________________
+163 ;;
+164 ;; Phone: ____________________________ FAX: _______________________________
+165 ;;
+166 ;; NOTE: VA may request additional medical information, including additional
+167 ;; examinations if necessary to complete VA's review of the Veteran's
+168 ;; application.
+169 ;;
+170 ;;^END^
+171 QUIT
