DVBCQMI2 ;;ALB-CIOFO/SBW - MUSCLE INJURIES QUESTIONNAIRE ; 16/JUNE/2011
;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
;
TXT ;
;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
;; disability benefits. VA will consider the information you provide on this
;; questionnaire as part of their evaluation in processing the Veteran's claim.
;;
;; SECTION I: DIAGNOSIS
;; Does the Veteran now have or has he/she ever been diagnosed with a muscle
;; injury?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to muscle injury(ies):
;; Diagnosis #1: __________________
;; ICD code: ___________________
;; Date of diagnosis: _____________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; Diagnosis #2: __________________
;; ICD code: ___________________
;; Date of diagnosis: _____________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; Diagnosis #3: __________________
;; ICD code: ___________________
;; Date of diagnosis: _____________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; If there are additional diagnoses pertaining to muscle injuries, list using
;; above format: _______________________________________________________________
;;
;; NOTE: If there are multiple muscle injuries, complete the assessment for all
;; muscle injuries on this Questionnaire, if possible. If unable to complete
;; assessment for all muscle injuries on this Questionnaire, also complete an
;; additional Questionnaire for each additional injury.
;;
;; If the Veteran has or has had a muscle injury that results in any conditions
;; that are not covered in this Questionnaire, also complete any other
;; appropriate Questionnaires (e.g., if peripheral nerve injury also exists due
;; to the muscle injury, complete the Peripheral Nerves Questionnaire).
;;
;; SECTION II: HISTORY OF MUSCLE INJURY
;; a. Does the Veteran have a penetrating muscle injury, such as a gunshot or
;; shell fragment wound?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have a non-penetrating muscle injury (such as a muscle
;; strain, torn Achilles tendon or torn quadriceps muscle)?
;; ___ Yes ___ No
;;
;; c. Describe the history (including onset and course) of the Veteran's muscle
;; injury: (brief summary): ___________________________________________________
;;
;; d. Dominant hand
;; ___ Right ___ Left ___ Ambidextrous
;;
;; SECTION III: LOCATION OF MUSCLE INJURY
;; NOTE: For VA purposes, muscles are classified into groups I-XXIII. In this
;; section, indicate the location of the Veteran's muscle injuries by checking
;; the muscle groups involved.
;;
;; 1. Shoulder girdle and arm
;; Does the Veteran now have or has he/she ever had an injury to a muscle group
;; of the shoulder girdle or arm?
;; ___ Yes ___ No
;; If yes, check muscle group(s) and side affected (check all that apply):
;;
;; ___ Group I: Extrinsic muscles of shoulder girdle: trapezius, levator
;; scapulae, serratus magnus
;; Function: Upward rotation of scapula, elevation of arm above shoulder level
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group II: Muscles of shoulder girdle: pectoralis major, latissimus
;; dorsi and teres major, pectoralis minor, rhomboid
;; Function: Depression of arm from vertical overhead to hanging at side,
;; downward rotation of scapula, forward and backward swing of arm
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group III: Intrinsic muscles of shoulder girdle: pectoralis major,
;; deltoid
;; Function: Elevation and abduction of arm to level of shoulder, forward
;; and backward swing of arm.
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group IV: Shoulder girdle muscles: supraspinatus, infraspinatus and
;; teres minor, subscapularis, coracobrachialis
;; Function: Stabilization of shoulder, abduction, rotation of arm
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group V: Flexor muscles of elbow: biceps, brachialis, brachioradialis
;; Function: Flexion of elbow
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group VI: Extensor muscles of elbow: triceps
;; Function: Extension of elbow
;; Side affected: ___ Right ___ Left ___ Both
;;^TOF^
;; 2. Forearm and hand
;; Does the Veteran now have or has he/she ever had an injury to a muscle group
;; of the forearm or hand?
;; ___ Yes ___ No
;; If yes, check muscle group(s) and side affected (check all that apply):
;; ___ Group VII: Muscles of forearm: Flexors of the wrist, fingers and thumb
;; Function: Flexion of wrist and fingers
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group VIII: Muscles: Extensors of the wrist, fingers and thumb
;; Function: Extension of wrist, fingers and thumb
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group IX: Intrinsic muscles of hand, including muscles in the thenar
;; and hypothenar eminence, lumbricales, dorsal and palmar interossei
;; Function: Intrinsic muscles of the hand assist in delicate manipulative
;; movements
;; Side affected: ___ Right ___ Left ___ Both
;;
;; 3. Foot and leg
;; Does the Veteran now have or has he/she ever had an injury to a muscle group
;; of the foot or leg?
;; ___ Yes ___ No
;; If yes, check muscle group(s) and side affected (check all that apply):
;;
;; ___ Group X: Muscles of the foot: flexor digitorum brevis, abductor
;; hallucis, abductor digiti minimi, quadratus plantae, lumbricales, flexor
;; hallucis brevis, adductor hallucis, flexor digiti minimi brevis, dorsal
;; and plantar interossei
;; Function: Movements of forefoot and toes, propulsion thrust in walking
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group XI: Muscles of the foot, ankle and calf: gastrocnemius, soleus,
;; tibalis posterior, peroneus longus, peroneus brevis, flexor hallucis
;; longus, flexor digitorum longus
;; Function: Propulsion, plantar flexion of foot, stabilization of arch,
;; flexion of toes
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group XII: Anterior muscles of the leg: tibalis anterior, extensor
;; digitorum longus, extensor hallucis longus, peroneus tertius
;; Function: Dorsiflexion, extension of toes, stabilization of arch
;; Side affected: ___ Right ___ Left ___ Both
;;^TOF^
;; 4. Pelvic girdle and thigh
;; Does the Veteran now have or has he/she ever had an injury to a muscle group
;; of the pelvic girdle or thigh?
;; ___ Yes ___ No
;; If yes, check muscle group(s) and side affected (check all that apply):
;;
;; ___ Group XIII: Posterior thigh/hamstring muscles: biceps femoris,
;; semimembranosus, semitendinosus
;; Function: Flexion of knee
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group XIV: Anterior thigh muscles: sartorius, rectus femoris,
;; quadriceps
;; Function: Extension of knee
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group XV: Medial thigh muscles: adductor longus, adductor brevis,
;; adductor magnus, gracilis
;; Function: Adduction of hip
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group XVI: Pelvic girdle muscles: psoas, iliacus, pectineus
;; Function: Flexion of hip
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group XVII: Pelvic girdle muscles: gluteus maximus, gluteus medius,
;; gluteus minimus
;; Function: Extension of hip, abduction of thigh, postural support of body
;; Side affected: ___ Right ___ Left ___ Both
;;
;; If checked, is there severe damage to muscle group XVII, such that
;; Veteran is unable to rise from a seated and stooped position and to
;; maintain postural stability without assistance of any type?
;; ___ Yes ___ No
;;
;; ___ Group XVIII: Pelvic girdle muscles: pyriformis, gemelli, obturator,
;; quadratus femoris
;; Function: Outward rotation of thigh and stabilization of hip joint
;; Side affected: ___ Right ___ Left ___ Both
;;^TOF^
;; 5. Torso and neck
;; Does the Veteran now have or has he/she ever had an injury to a muscle group
;; in the torso and/or neck?
;; ___ Yes ___ No
;; If yes, check muscle group(s) and side or region affected (check all that
;; apply):
;;
;; ___ Group XIX: Muscles of the abdominal wall: rectus abdominis, external
;; oblique, internal oblique, transversalis, quadratus lumborum
;; Function: Support of abdominal wall and lower thorax, flexion and lateral
;; movement of spine
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group XX: Spinal muscles: sacrospinalis, erector spinae
;; Function: Postural support of body, extension and lateral movement of
;; the spine
;; Region affected: ___ Cervical ___ Thoracic ___ Lumbar
;;
;; ___ Group XXI: Muscles of respiration: thoracic muscle group.
;; Function: Respiration
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group XXII: Muscles of the front of the neck: trapezius,
;; sternocleidomastoid, hyoid muscles, sternothyroid, digastric
;; Function: Rotation and flexion of the head, respiration, swallowing
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ Group XXIII: Muscles of the side and back of the neck: suboccipital,
;; lateral vertebral and anterior vertebral muscles
;; Function: Movements of the head, fixation of shoulder movements
;; Side affected: ___ Right ___ Left ___ Both
;;
;; 6. Additional conditions
;; a. Does the Veteran have a history of rupture of the diaphragm with herniation?
;; ___ Yes ___ No
;; If yes, also complete Hiatal Hernia Questionnaire.
;;
;; b. Does the Veteran have a history of an extensive muscle hernia of any
;; muscle, without other injury to the muscle?
;; ___ Yes ___ No
;; If yes, name muscle and describe current residuals __________________________
;;
;; c. Does the Veteran have a history of injury to the facial muscles?
;; ___ Yes ___ No
;; If yes, complete the Questionnaire for Cranial Nerves, Scars, etc., as
;; indicated by type of residuals.
;; If yes, is there interference to any extent with mastication?
;; ___ Yes ___ No
;;^TOF^
;; SECTION IV: MUSCLE INJURY EXAM
;; 1. Scar, fascia and muscle findings
;; a. Does the Veteran have any scar(s) associated with a muscle injury?
;; ___ Yes ___ No
;; If yes, indicate severity of scar(s) caused by the muscle injury(ies) (check
;; all that apply if there is more than one area or type of scarring):
;; ___ Minimal scar(s)
;; ___ Entrance and (if present) exit scars are small or linear, indicating
;; short track of missile through muscle tissue
;; ___ Entrance and (if present) exit scars indicating track of missile
;; through one or more muscle groups
;; ___ Ragged, depressed and adherent scars indicating wide damage to muscle
;; groups in missile track
;; ___ Adhesion of scar to one of the long bones, scapula, pelvic bones,
;; sacrum or vertebrae, with epithelial sealing over the bone rather
;; than true skin covering in an area where bone is normally protected
;; by muscle
;; ___ Other (including surgical scars related to muscle injuries shown
;; above), also complete Scars Questionnaire
;;
;; b. Does the Veteran have any known fascial defects or evidence of fascial
;; defects associated with any muscle injuries?
;; ___ Yes ___ No
;; If yes, indicate severity of fascial defect(s) caused by the muscle injury(ies)
;; (check all that apply if there is more than one area/type of fascial defect):
;; ___ Some loss of deep fascia
;; ___ Palpation shows loss of deep fascia
;; ___ Other, describe: _____________________________________________________
;;
;; c. Does the Veteran's muscle injury(ies) affect muscle substance or function?
;; ___ Yes ___ No
;; If yes, indicate effect of the muscle injury(ies) on muscle substance or
;; function (check all that apply):
;; ___ Some impairment of muscle tonus
;; ___ Some loss of muscle substance
;; ___ Soft flabby muscles in wound area
;; ___ Muscles swell and harden abnormally in contraction
;; ___ Induration or atrophy of an entire muscle following history of simple
;; piercing by a projectile
;; ___ Adaptive contraction of an opposing group of muscles
;; ___ Visible or measurable atrophy
;; ___ Atrophy of muscle groups not in the track of the missile, particularly
;; of the trapezius and serratus in wounds of the shoulder girdle
;; ___ Tests of endurance or coordinated movements compared with the
;; corresponding muscles of the uninjured side indicate severe
;; impairment of function
;; ___ Other, describe: ____________________________________________________
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQMI2 13591 printed Oct 16, 2024@17:48:03 Page 2
DVBCQMI2 ;;ALB-CIOFO/SBW - MUSCLE INJURIES QUESTIONNAIRE ; 16/JUNE/2011
+1 ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;;
+5 ;; SECTION I: DIAGNOSIS
+6 ;; Does the Veteran now have or has he/she ever been diagnosed with a muscle
+7 ;; injury?
+8 ;; ___ Yes ___ No
+9 ;;
+10 ;; If yes, provide only diagnoses that pertain to muscle injury(ies):
+11 ;; Diagnosis #1: __________________
+12 ;; ICD code: ___________________
+13 ;; Date of diagnosis: _____________
+14 ;; Side affected: ___ Right ___ Left ___ Both
+15 ;;
+16 ;; Diagnosis #2: __________________
+17 ;; ICD code: ___________________
+18 ;; Date of diagnosis: _____________
+19 ;; Side affected: ___ Right ___ Left ___ Both
+20 ;;
+21 ;; Diagnosis #3: __________________
+22 ;; ICD code: ___________________
+23 ;; Date of diagnosis: _____________
+24 ;; Side affected: ___ Right ___ Left ___ Both
+25 ;;
+26 ;; If there are additional diagnoses pertaining to muscle injuries, list using
+27 ;; above format: _______________________________________________________________
+28 ;;
+29 ;; NOTE: If there are multiple muscle injuries, complete the assessment for all
+30 ;; muscle injuries on this Questionnaire, if possible. If unable to complete
+31 ;; assessment for all muscle injuries on this Questionnaire, also complete an
+32 ;; additional Questionnaire for each additional injury.
+33 ;;
+34 ;; If the Veteran has or has had a muscle injury that results in any conditions
+35 ;; that are not covered in this Questionnaire, also complete any other
+36 ;; appropriate Questionnaires (e.g., if peripheral nerve injury also exists due
+37 ;; to the muscle injury, complete the Peripheral Nerves Questionnaire).
+38 ;;
+39 ;; SECTION II: HISTORY OF MUSCLE INJURY
+40 ;; a. Does the Veteran have a penetrating muscle injury, such as a gunshot or
+41 ;; shell fragment wound?
+42 ;; ___ Yes ___ No
+43 ;;
+44 ;; b. Does the Veteran have a non-penetrating muscle injury (such as a muscle
+45 ;; strain, torn Achilles tendon or torn quadriceps muscle)?
+46 ;; ___ Yes ___ No
+47 ;;
+48 ;; c. Describe the history (including onset and course) of the Veteran's muscle
+49 ;; injury: (brief summary): ___________________________________________________
+50 ;;
+51 ;; d. Dominant hand
+52 ;; ___ Right ___ Left ___ Ambidextrous
+53 ;;
+54 ;; SECTION III: LOCATION OF MUSCLE INJURY
+55 ;; NOTE: For VA purposes, muscles are classified into groups I-XXIII. In this
+56 ;; section, indicate the location of the Veteran's muscle injuries by checking
+57 ;; the muscle groups involved.
+58 ;;
+59 ;; 1. Shoulder girdle and arm
+60 ;; Does the Veteran now have or has he/she ever had an injury to a muscle group
+61 ;; of the shoulder girdle or arm?
+62 ;; ___ Yes ___ No
+63 ;; If yes, check muscle group(s) and side affected (check all that apply):
+64 ;;
+65 ;; ___ Group I: Extrinsic muscles of shoulder girdle: trapezius, levator
+66 ;; scapulae, serratus magnus
+67 ;; Function: Upward rotation of scapula, elevation of arm above shoulder level
+68 ;; Side affected: ___ Right ___ Left ___ Both
+69 ;;
+70 ;; ___ Group II: Muscles of shoulder girdle: pectoralis major, latissimus
+71 ;; dorsi and teres major, pectoralis minor, rhomboid
+72 ;; Function: Depression of arm from vertical overhead to hanging at side,
+73 ;; downward rotation of scapula, forward and backward swing of arm
+74 ;; Side affected: ___ Right ___ Left ___ Both
+75 ;;
+76 ;; ___ Group III: Intrinsic muscles of shoulder girdle: pectoralis major,
+77 ;; deltoid
+78 ;; Function: Elevation and abduction of arm to level of shoulder, forward
+79 ;; and backward swing of arm.
+80 ;; Side affected: ___ Right ___ Left ___ Both
+81 ;;
+82 ;; ___ Group IV: Shoulder girdle muscles: supraspinatus, infraspinatus and
+83 ;; teres minor, subscapularis, coracobrachialis
+84 ;; Function: Stabilization of shoulder, abduction, rotation of arm
+85 ;; Side affected: ___ Right ___ Left ___ Both
+86 ;;
+87 ;; ___ Group V: Flexor muscles of elbow: biceps, brachialis, brachioradialis
+88 ;; Function: Flexion of elbow
+89 ;; Side affected: ___ Right ___ Left ___ Both
+90 ;;
+91 ;; ___ Group VI: Extensor muscles of elbow: triceps
+92 ;; Function: Extension of elbow
+93 ;; Side affected: ___ Right ___ Left ___ Both
+94 ;;^TOF^
+95 ;; 2. Forearm and hand
+96 ;; Does the Veteran now have or has he/she ever had an injury to a muscle group
+97 ;; of the forearm or hand?
+98 ;; ___ Yes ___ No
+99 ;; If yes, check muscle group(s) and side affected (check all that apply):
+100 ;; ___ Group VII: Muscles of forearm: Flexors of the wrist, fingers and thumb
+101 ;; Function: Flexion of wrist and fingers
+102 ;; Side affected: ___ Right ___ Left ___ Both
+103 ;;
+104 ;; ___ Group VIII: Muscles: Extensors of the wrist, fingers and thumb
+105 ;; Function: Extension of wrist, fingers and thumb
+106 ;; Side affected: ___ Right ___ Left ___ Both
+107 ;;
+108 ;; ___ Group IX: Intrinsic muscles of hand, including muscles in the thenar
+109 ;; and hypothenar eminence, lumbricales, dorsal and palmar interossei
+110 ;; Function: Intrinsic muscles of the hand assist in delicate manipulative
+111 ;; movements
+112 ;; Side affected: ___ Right ___ Left ___ Both
+113 ;;
+114 ;; 3. Foot and leg
+115 ;; Does the Veteran now have or has he/she ever had an injury to a muscle group
+116 ;; of the foot or leg?
+117 ;; ___ Yes ___ No
+118 ;; If yes, check muscle group(s) and side affected (check all that apply):
+119 ;;
+120 ;; ___ Group X: Muscles of the foot: flexor digitorum brevis, abductor
+121 ;; hallucis, abductor digiti minimi, quadratus plantae, lumbricales, flexor
+122 ;; hallucis brevis, adductor hallucis, flexor digiti minimi brevis, dorsal
+123 ;; and plantar interossei
+124 ;; Function: Movements of forefoot and toes, propulsion thrust in walking
+125 ;; Side affected: ___ Right ___ Left ___ Both
+126 ;;
+127 ;; ___ Group XI: Muscles of the foot, ankle and calf: gastrocnemius, soleus,
+128 ;; tibalis posterior, peroneus longus, peroneus brevis, flexor hallucis
+129 ;; longus, flexor digitorum longus
+130 ;; Function: Propulsion, plantar flexion of foot, stabilization of arch,
+131 ;; flexion of toes
+132 ;; Side affected: ___ Right ___ Left ___ Both
+133 ;;
+134 ;; ___ Group XII: Anterior muscles of the leg: tibalis anterior, extensor
+135 ;; digitorum longus, extensor hallucis longus, peroneus tertius
+136 ;; Function: Dorsiflexion, extension of toes, stabilization of arch
+137 ;; Side affected: ___ Right ___ Left ___ Both
+138 ;;^TOF^
+139 ;; 4. Pelvic girdle and thigh
+140 ;; Does the Veteran now have or has he/she ever had an injury to a muscle group
+141 ;; of the pelvic girdle or thigh?
+142 ;; ___ Yes ___ No
+143 ;; If yes, check muscle group(s) and side affected (check all that apply):
+144 ;;
+145 ;; ___ Group XIII: Posterior thigh/hamstring muscles: biceps femoris,
+146 ;; semimembranosus, semitendinosus
+147 ;; Function: Flexion of knee
+148 ;; Side affected: ___ Right ___ Left ___ Both
+149 ;;
+150 ;; ___ Group XIV: Anterior thigh muscles: sartorius, rectus femoris,
+151 ;; quadriceps
+152 ;; Function: Extension of knee
+153 ;; Side affected: ___ Right ___ Left ___ Both
+154 ;;
+155 ;; ___ Group XV: Medial thigh muscles: adductor longus, adductor brevis,
+156 ;; adductor magnus, gracilis
+157 ;; Function: Adduction of hip
+158 ;; Side affected: ___ Right ___ Left ___ Both
+159 ;;
+160 ;; ___ Group XVI: Pelvic girdle muscles: psoas, iliacus, pectineus
+161 ;; Function: Flexion of hip
+162 ;; Side affected: ___ Right ___ Left ___ Both
+163 ;;
+164 ;; ___ Group XVII: Pelvic girdle muscles: gluteus maximus, gluteus medius,
+165 ;; gluteus minimus
+166 ;; Function: Extension of hip, abduction of thigh, postural support of body
+167 ;; Side affected: ___ Right ___ Left ___ Both
+168 ;;
+169 ;; If checked, is there severe damage to muscle group XVII, such that
+170 ;; Veteran is unable to rise from a seated and stooped position and to
+171 ;; maintain postural stability without assistance of any type?
+172 ;; ___ Yes ___ No
+173 ;;
+174 ;; ___ Group XVIII: Pelvic girdle muscles: pyriformis, gemelli, obturator,
+175 ;; quadratus femoris
+176 ;; Function: Outward rotation of thigh and stabilization of hip joint
+177 ;; Side affected: ___ Right ___ Left ___ Both
+178 ;;^TOF^
+179 ;; 5. Torso and neck
+180 ;; Does the Veteran now have or has he/she ever had an injury to a muscle group
+181 ;; in the torso and/or neck?
+182 ;; ___ Yes ___ No
+183 ;; If yes, check muscle group(s) and side or region affected (check all that
+184 ;; apply):
+185 ;;
+186 ;; ___ Group XIX: Muscles of the abdominal wall: rectus abdominis, external
+187 ;; oblique, internal oblique, transversalis, quadratus lumborum
+188 ;; Function: Support of abdominal wall and lower thorax, flexion and lateral
+189 ;; movement of spine
+190 ;; Side affected: ___ Right ___ Left ___ Both
+191 ;;
+192 ;; ___ Group XX: Spinal muscles: sacrospinalis, erector spinae
+193 ;; Function: Postural support of body, extension and lateral movement of
+194 ;; the spine
+195 ;; Region affected: ___ Cervical ___ Thoracic ___ Lumbar
+196 ;;
+197 ;; ___ Group XXI: Muscles of respiration: thoracic muscle group.
+198 ;; Function: Respiration
+199 ;; Side affected: ___ Right ___ Left ___ Both
+200 ;;
+201 ;; ___ Group XXII: Muscles of the front of the neck: trapezius,
+202 ;; sternocleidomastoid, hyoid muscles, sternothyroid, digastric
+203 ;; Function: Rotation and flexion of the head, respiration, swallowing
+204 ;; Side affected: ___ Right ___ Left ___ Both
+205 ;;
+206 ;; ___ Group XXIII: Muscles of the side and back of the neck: suboccipital,
+207 ;; lateral vertebral and anterior vertebral muscles
+208 ;; Function: Movements of the head, fixation of shoulder movements
+209 ;; Side affected: ___ Right ___ Left ___ Both
+210 ;;
+211 ;; 6. Additional conditions
+212 ;; a. Does the Veteran have a history of rupture of the diaphragm with herniation?
+213 ;; ___ Yes ___ No
+214 ;; If yes, also complete Hiatal Hernia Questionnaire.
+215 ;;
+216 ;; b. Does the Veteran have a history of an extensive muscle hernia of any
+217 ;; muscle, without other injury to the muscle?
+218 ;; ___ Yes ___ No
+219 ;; If yes, name muscle and describe current residuals __________________________
+220 ;;
+221 ;; c. Does the Veteran have a history of injury to the facial muscles?
+222 ;; ___ Yes ___ No
+223 ;; If yes, complete the Questionnaire for Cranial Nerves, Scars, etc., as
+224 ;; indicated by type of residuals.
+225 ;; If yes, is there interference to any extent with mastication?
+226 ;; ___ Yes ___ No
+227 ;;^TOF^
+228 ;; SECTION IV: MUSCLE INJURY EXAM
+229 ;; 1. Scar, fascia and muscle findings
+230 ;; a. Does the Veteran have any scar(s) associated with a muscle injury?
+231 ;; ___ Yes ___ No
+232 ;; If yes, indicate severity of scar(s) caused by the muscle injury(ies) (check
+233 ;; all that apply if there is more than one area or type of scarring):
+234 ;; ___ Minimal scar(s)
+235 ;; ___ Entrance and (if present) exit scars are small or linear, indicating
+236 ;; short track of missile through muscle tissue
+237 ;; ___ Entrance and (if present) exit scars indicating track of missile
+238 ;; through one or more muscle groups
+239 ;; ___ Ragged, depressed and adherent scars indicating wide damage to muscle
+240 ;; groups in missile track
+241 ;; ___ Adhesion of scar to one of the long bones, scapula, pelvic bones,
+242 ;; sacrum or vertebrae, with epithelial sealing over the bone rather
+243 ;; than true skin covering in an area where bone is normally protected
+244 ;; by muscle
+245 ;; ___ Other (including surgical scars related to muscle injuries shown
+246 ;; above), also complete Scars Questionnaire
+247 ;;
+248 ;; b. Does the Veteran have any known fascial defects or evidence of fascial
+249 ;; defects associated with any muscle injuries?
+250 ;; ___ Yes ___ No
+251 ;; If yes, indicate severity of fascial defect(s) caused by the muscle injury(ies)
+252 ;; (check all that apply if there is more than one area/type of fascial defect):
+253 ;; ___ Some loss of deep fascia
+254 ;; ___ Palpation shows loss of deep fascia
+255 ;; ___ Other, describe: _____________________________________________________
+256 ;;
+257 ;; c. Does the Veteran's muscle injury(ies) affect muscle substance or function?
+258 ;; ___ Yes ___ No
+259 ;; If yes, indicate effect of the muscle injury(ies) on muscle substance or
+260 ;; function (check all that apply):
+261 ;; ___ Some impairment of muscle tonus
+262 ;; ___ Some loss of muscle substance
+263 ;; ___ Soft flabby muscles in wound area
+264 ;; ___ Muscles swell and harden abnormally in contraction
+265 ;; ___ Induration or atrophy of an entire muscle following history of simple
+266 ;; piercing by a projectile
+267 ;; ___ Adaptive contraction of an opposing group of muscles
+268 ;; ___ Visible or measurable atrophy
+269 ;; ___ Atrophy of muscle groups not in the track of the missile, particularly
+270 ;; of the trapezius and serratus in wounds of the shoulder girdle
+271 ;; ___ Tests of endurance or coordinated movements compared with the
+272 ;; corresponding muscles of the uninjured side indicate severe
+273 ;; impairment of function
+274 ;; ___ Other, describe: ____________________________________________________
+275 QUIT
