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Routine: DVBCQMI2

DVBCQMI2.m

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  1. DVBCQMI2 ;;ALB-CIOFO/SBW - MUSCLE INJURIES QUESTIONNAIRE ; 16/JUNE/2011
  1.  ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1.  ;; disability benefits.  VA will consider the information you provide on this
  1.  ;; questionnaire as part of their evaluation in processing the Veteran's claim. 
  1.  ;;
  1.  ;; SECTION I: DIAGNOSIS
  1.  ;; Does the Veteran now have or has he/she ever been diagnosed with a muscle
  1.  ;; injury?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide only diagnoses that pertain to muscle injury(ies):
  1.  ;;    Diagnosis #1: __________________
  1.  ;;    ICD code: ___________________
  1.  ;;    Date of diagnosis: _____________
  1.  ;;    Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;    Diagnosis #2: __________________
  1.  ;;    ICD code: ___________________
  1.  ;;    Date of diagnosis: _____________
  1.  ;;    Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;    Diagnosis #3: __________________
  1.  ;;    ICD code: ___________________
  1.  ;;    Date of diagnosis: _____________
  1.  ;;    Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; If there are additional diagnoses pertaining to muscle injuries, list using
  1.  ;; above format: _______________________________________________________________
  1.  ;;
  1.  ;; NOTE: If there are multiple muscle injuries, complete the assessment for all
  1.  ;; muscle injuries on this Questionnaire, if possible. If unable to complete
  1.  ;; assessment for all muscle injuries on this Questionnaire, also complete an
  1.  ;; additional Questionnaire for each additional injury.
  1.  ;; 
  1.  ;; If the Veteran has or has had a muscle injury that results in any conditions
  1.  ;; that are not covered in this Questionnaire, also complete any other
  1.  ;; appropriate Questionnaires (e.g., if peripheral nerve injury also exists due
  1.  ;; to the muscle injury, complete the Peripheral Nerves Questionnaire).
  1.  ;;
  1.  ;; SECTION II: HISTORY OF MUSCLE INJURY
  1.  ;; a. Does the Veteran have a penetrating muscle injury, such as a gunshot or
  1.  ;; shell fragment wound?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; b. Does the Veteran have a non-penetrating muscle injury (such as a muscle
  1.  ;; strain, torn Achilles tendon or torn quadriceps muscle)?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; c. Describe the history (including onset and course) of the Veteran's muscle
  1.  ;; injury:  (brief summary): ___________________________________________________
  1.  ;;
  1.  ;; d. Dominant hand
  1.  ;; ___ Right   ___ Left   ___ Ambidextrous
  1.  ;;
  1.  ;; SECTION III: LOCATION OF MUSCLE INJURY
  1.  ;; NOTE: For VA purposes, muscles are classified into groups I-XXIII. In this
  1.  ;; section, indicate the location of the Veteran's muscle injuries by checking
  1.  ;; the muscle groups involved.
  1.  ;;
  1.  ;; 1. Shoulder girdle and arm
  1.  ;; Does the Veteran now have or has he/she ever had an injury to a muscle group
  1.  ;; of the shoulder girdle or arm?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check muscle group(s) and side affected (check all that apply):
  1.  ;;
  1.  ;;     ___ Group I: Extrinsic muscles of shoulder girdle: trapezius, levator
  1.  ;;     scapulae, serratus magnus
  1.  ;;     Function: Upward rotation of scapula, elevation of arm above shoulder level
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group II: Muscles of shoulder girdle: pectoralis major, latissimus
  1.  ;;     dorsi and teres major, pectoralis minor, rhomboid
  1.  ;;     Function: Depression of arm from vertical overhead to hanging at side,
  1.  ;;     downward rotation of scapula, forward and backward swing of arm  
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group III: Intrinsic muscles of shoulder girdle: pectoralis major,
  1.  ;;     deltoid
  1.  ;;     Function: Elevation and abduction of arm to level of shoulder, forward
  1.  ;;     and backward swing of arm.
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group IV: Shoulder girdle muscles: supraspinatus, infraspinatus and
  1.  ;;     teres minor, subscapularis, coracobrachialis
  1.  ;;     Function: Stabilization of shoulder, abduction, rotation of arm 
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group V: Flexor muscles of elbow:  biceps, brachialis, brachioradialis
  1.  ;;     Function: Flexion of elbow
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group VI: Extensor muscles of elbow: triceps
  1.  ;;     Function: Extension of elbow
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;^TOF^
  1.  ;; 2. Forearm and hand
  1.  ;; Does the Veteran now have or has he/she ever had an injury to a muscle group
  1.  ;; of the forearm or hand?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check muscle group(s) and side affected (check all that apply):
  1.  ;;     ___ Group VII:  Muscles of forearm: Flexors of the wrist, fingers and thumb
  1.  ;;     Function: Flexion of wrist and fingers
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group VIII:  Muscles: Extensors of the wrist, fingers and thumb
  1.  ;;     Function: Extension of wrist, fingers and thumb 
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group IX:  Intrinsic muscles of hand, including muscles in the thenar
  1.  ;;     and hypothenar eminence, lumbricales, dorsal and palmar interossei
  1.  ;;     Function: Intrinsic  muscles of the hand assist in delicate manipulative
  1.  ;;     movements
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; 3. Foot and leg
  1.  ;; Does the Veteran now have or has he/she ever had an injury to a muscle group
  1.  ;; of the foot or leg?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check muscle group(s) and side affected (check all that apply):
  1.  ;;
  1.  ;;     ___ Group X:  Muscles of the foot:  flexor digitorum brevis, abductor
  1.  ;;     hallucis, abductor digiti minimi, quadratus plantae, lumbricales, flexor
  1.  ;;     hallucis brevis, adductor hallucis, flexor digiti minimi brevis, dorsal
  1.  ;;     and plantar interossei
  1.  ;;     Function: Movements of forefoot and toes, propulsion thrust in walking
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group XI:  Muscles of the foot, ankle and calf: gastrocnemius, soleus,
  1.  ;;     tibalis posterior, peroneus longus, peroneus brevis, flexor hallucis
  1.  ;;     longus, flexor digitorum longus
  1.  ;;     Function: Propulsion, plantar flexion of foot, stabilization of arch,
  1.  ;;     flexion of toes
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group XII:  Anterior muscles of the leg: tibalis anterior, extensor
  1.  ;;     digitorum longus, extensor hallucis longus, peroneus tertius
  1.  ;;     Function: Dorsiflexion, extension of toes, stabilization of arch 
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;^TOF^
  1.  ;; 4. Pelvic girdle and thigh
  1.  ;; Does the Veteran now have or has he/she ever had an injury to a muscle group
  1.  ;; of the pelvic girdle or thigh?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check muscle group(s) and side affected (check all that apply):
  1.  ;;
  1.  ;;     ___ Group XIII:  Posterior thigh/hamstring muscles:  biceps femoris,
  1.  ;;     semimembranosus, semitendinosus
  1.  ;;     Function: Flexion of knee 
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group XIV:  Anterior thigh muscles: sartorius, rectus femoris,
  1.  ;;     quadriceps
  1.  ;;     Function: Extension of knee
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group XV:  Medial thigh muscles: adductor longus, adductor brevis,
  1.  ;;     adductor magnus, gracilis
  1.  ;;     Function: Adduction of hip
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group XVI:  Pelvic girdle muscles: psoas, iliacus, pectineus
  1.  ;;     Function: Flexion of hip
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group XVII: Pelvic girdle muscles: gluteus maximus, gluteus medius,
  1.  ;;     gluteus minimus
  1.  ;;     Function: Extension of hip, abduction of thigh, postural support of body
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;         If checked, is there severe damage to muscle group XVII, such that
  1.  ;;         Veteran is unable to rise from a seated and stooped position and to
  1.  ;;         maintain postural stability without assistance of any type?
  1.  ;;         ___ Yes   ___ No
  1.  ;;
  1.  ;;     ___ Group XVIII:  Pelvic girdle muscles:  pyriformis, gemelli, obturator,
  1.  ;;     quadratus femoris
  1.  ;;     Function: Outward rotation of thigh and stabilization of hip joint
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;^TOF^
  1.  ;; 5. Torso and neck
  1.  ;; Does the Veteran now have or has he/she ever had an injury to a muscle group
  1.  ;; in the torso and/or neck?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check muscle group(s) and side or region affected (check all that
  1.  ;;  apply):
  1.  ;;
  1.  ;;     ___ Group XIX:  Muscles of the abdominal wall: rectus abdominis, external
  1.  ;;     oblique, internal oblique, transversalis, quadratus lumborum
  1.  ;;     Function: Support of abdominal wall and lower thorax, flexion and lateral
  1.  ;;     movement of spine
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group XX:  Spinal muscles: sacrospinalis, erector spinae
  1.  ;;     Function: Postural support of body, extension and lateral movement of
  1.  ;;     the spine
  1.  ;;     Region affected: ___ Cervical   ___ Thoracic   ___ Lumbar
  1.  ;;
  1.  ;;     ___ Group XXI:  Muscles of respiration: thoracic muscle group.
  1.  ;;     Function: Respiration
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group XXII:  Muscles of the front of the neck: trapezius,
  1.  ;;     sternocleidomastoid, hyoid muscles, sternothyroid, digastric
  1.  ;;     Function: Rotation and flexion of the head, respiration, swallowing
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;     ___ Group XXIII:  Muscles of the side and back of the neck: suboccipital,
  1.  ;;     lateral vertebral and anterior vertebral muscles
  1.  ;;     Function: Movements of the head, fixation of shoulder movements
  1.  ;;     Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; 6. Additional conditions
  1.  ;; a. Does the Veteran have a history of rupture of the diaphragm with herniation?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, also complete Hiatal Hernia Questionnaire.
  1.  ;;
  1.  ;; b. Does the Veteran have a history of an extensive muscle hernia of any
  1.  ;; muscle, without other injury to the muscle?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, name muscle and describe current residuals __________________________
  1.  ;;
  1.  ;; c. Does the Veteran have a history of injury to the facial muscles?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If yes, complete the Questionnaire for Cranial Nerves, Scars, etc., as
  1.  ;;     indicated by type of residuals.
  1.  ;;     If yes, is there interference to any extent with mastication?
  1.  ;;      ___ Yes   ___ No
  1.  ;;^TOF^
  1.  ;; SECTION IV: MUSCLE INJURY EXAM
  1.  ;; 1. Scar, fascia and muscle findings
  1.  ;; a. Does the Veteran have any scar(s) associated with a muscle injury?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate severity of scar(s) caused by the muscle injury(ies) (check
  1.  ;; all that apply if there is more than one area or type of scarring):
  1.  ;;     ___ Minimal scar(s)
  1.  ;;     ___ Entrance and (if present) exit scars are small or linear, indicating
  1.  ;;         short track of missile through muscle tissue
  1.  ;;     ___ Entrance and (if present) exit scars indicating track of missile
  1.  ;;         through one or more muscle groups
  1.  ;;     ___ Ragged, depressed and adherent scars indicating wide damage to muscle
  1.  ;;         groups in missile track
  1.  ;;     ___ Adhesion of scar to one of the long bones, scapula, pelvic bones,
  1.  ;;         sacrum or vertebrae, with epithelial sealing over the bone rather
  1.  ;;         than true skin covering in an area where bone is normally protected
  1.  ;;         by muscle
  1.  ;;     ___ Other (including surgical scars related to muscle injuries shown
  1.  ;;         above), also complete Scars Questionnaire
  1.  ;;
  1.  ;; b. Does the Veteran have any known fascial defects or evidence of fascial
  1.  ;; defects associated with any muscle injuries?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate severity of fascial defect(s) caused by the muscle injury(ies)
  1.  ;; (check all that apply if there is more than one area/type of fascial defect):
  1.  ;;    ___ Some loss of deep fascia
  1.  ;;    ___ Palpation shows loss of deep fascia
  1.  ;;    ___ Other, describe: _____________________________________________________
  1.  ;;
  1.  ;; c. Does the Veteran's muscle injury(ies) affect muscle substance or function?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate effect of the muscle injury(ies) on muscle substance or
  1.  ;; function (check all that apply):
  1.  ;;     ___ Some impairment of muscle tonus
  1.  ;;     ___ Some loss of muscle substance
  1.  ;;     ___ Soft flabby muscles in wound area
  1.  ;;     ___ Muscles swell and harden abnormally in contraction
  1.  ;;     ___ Induration or atrophy of an entire muscle following history of simple
  1.  ;;         piercing by a projectile
  1.  ;;     ___ Adaptive contraction of an opposing group of muscles
  1.  ;;     ___ Visible or measurable atrophy
  1.  ;;     ___ Atrophy of muscle groups not in the track of the missile, particularly
  1.  ;;         of the trapezius and serratus in wounds of the shoulder girdle
  1.  ;;     ___ Tests of endurance or coordinated movements compared with the
  1.  ;;         corresponding muscles of the uninjured side indicate severe 
  1.  ;;         impairment of function
  1.  ;;     ___ Other, describe: ____________________________________________________
  1.  Q