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Routine: DVBCQKL3

DVBCQKL3.m

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  1. DVBCQKL3 ;;ALB-CIOFO/ECF -  KNEE AND LOWER LEG CONDITIONS QUESTIONNAIRE ; 6/15/2011
  1.  ;;2.7;AMIE;***172***;Apr 10, 1995;Build 3
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; 12. Meniscal conditions and meniscal surgery
  1.  ;;
  1.  ;; Has the Veteran had any meniscal conditions or surgical procedures for a
  1.  ;; meniscal condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, complete the following section:
  1.  ;;
  1.  ;; a. Does the Veteran now have or has he or she ever had a meniscus
  1.  ;; (semilunar cartilage) condition?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate severity and frequency of symptoms, and side affected:
  1.  ;;    ___ No symptoms                            ___Right   ___Left   ___Both
  1.  ;;    ___ Meniscal dislocation                   ___Right   ___Left   ___Both
  1.  ;;    ___ Meniscal tear                          ___Right   ___Left   ___Both
  1.  ;;    ___ Frequent episodes of joint "locking"   ___Right   ___Left   ___Both
  1.  ;;    ___ Frequent episodes of joint pain        ___Right   ___Left   ___Both
  1.  ;;    ___ Frequent episodes of joint effusion    ___Right   ___Left   ___Both
  1.  ;;
  1.  ;; b. Has the Veteran had a meniscectomy?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected: ___Right   ___Left   ___Both
  1.  ;;    Date of surgery: ___________________
  1.  ;;
  1.  ;; c. Does the Veteran have any residual signs and/or symptoms due to a
  1.  ;; meniscectomy?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected: ___Right   ___Left   ___Both
  1.  ;;    Describe residuals: _____________________________________________________
  1.  ;;^TOF^
  1.  ;; 13. Joint replacement and other surgical procedures
  1.  ;;
  1.  ;; a. Has the Veteran had a total knee joint replacement?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side and severity of residuals.
  1.  ;;    ___ Right knee
  1.  ;;        Date of surgery: ___________________
  1.  ;;        Residuals:
  1.  ;;           ___ None
  1.  ;;           ___ Intermediate degrees of residual weakness, pain or limitation
  1.  ;;               of motion
  1.  ;;           ___Chronic residuals consisting of severe painful motion or
  1.  ;;               weakness
  1.  ;;           ___Other, describe: ___________________________________________
  1.  ;;    ___ Left knee
  1.  ;;        Date of surgery: ___________________
  1.  ;;        Residuals:
  1.  ;;           ___None
  1.  ;;           ___Intermediate degrees of residual weakness, pain or limitation
  1.  ;;              of motion
  1.  ;;           ___Chronic residuals consisting of severe painful motion or
  1.  ;;              weakness
  1.  ;;           ___Other, describe: ______________________________________________
  1.  ;;
  1.  ;; b. Has the Veteran had arthroscopic or other knee surgery not described
  1.  ;; above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:  ___Right   ___Left   ___Both
  1.  ;;    Date and type of surgery: _____________
  1.  ;;
  1.  ;; c. Does the Veteran have any residual signs and/or symptoms due to
  1.  ;; arthroscopic or other knee surgery not described above?
  1.  ;; ___Yes    ___No
  1.  ;; If yes, indicate side affected:  ___Right   ___Left   ___Both
  1.  ;;    Describe residuals: _____________________________________________________
  1.  ;;
  1.  ;; 14. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, are any of the scars painful and/or unstable, or is the total area
  1.  ;; of all related scars greater than 39 square cm (6 square inches)?
  1.  ;;    ___ Yes   ___ No
  1.  ;;        If yes, also complete a Scars Questionnaire.
  1.  ;;^TOF^
  1.  ;; b. Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs and/or symptoms related to any
  1.  ;; conditions listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): _________________________
  1.  ;;
  1.  ;; 15. Assistive devices
  1.  ;;
  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.  ;;
  1.  ;; 16. Remaining effective function of the extremities
  1.  ;;
  1.  ;; Due to the Veteran's knee and/or lower leg condition(s), is there functional
  1.  ;; impairment of an extremity such that no effective function remains other than
  1.  ;; that which would be equally well served by an amputation with prosthesis?
  1.  ;; (Functions of the upper extremity include grasping, manipulation, etc.,
  1.  ;; while functions for the lower extremity include balance and propulsion,
  1.  ;; etc.)
  1.  ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
  1.  ;; equally serve the Veteran.
  1.  ;;  ___ No
  1.  ;; If yes, indicate extremity(ies) 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.  ;;^TOF^
  1.  ;; 17.  Diagnostic testing
  1.  ;;
  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 required by VA, even if
  1.  ;; arthritis has worsened.
  1.  ;;
  1.  ;; a. Have imaging studies of the knee 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 knee: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Does the Veteran have x-ray evidence of patellar subluxation?
  1.  ;; ___ Yes   ___ No
  1.  ;;    If yes, indicate affected side(s):   ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; c. 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 summary):
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; 18. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's knee and/or lower leg condition(s) impact his or her
  1.  ;; ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe the impact of each of the Veteran's knee and/or lower leg
  1.  ;; conditions providing one or more examples: _________________________________
  1.  ;;
  1.  ;; 19. 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.  ;;
  1.  ;;^END^
  1.  Q