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Routine: DVBCQMI3

DVBCQMI3.m

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  1. DVBCQMI3 ;;ALB-CIOFO/SBW - MUSCLE INJURIES QUESTIONNAIRE ; 20/JUNE/2011
  1.  ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;;^TOF^
  1.  ;; 2. Cardinal signs and symptoms of muscle disability 
  1.  ;; Does the Veteran have any of the following signs and/or symptoms attributable
  1.  ;; to any muscle injuries?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply, and indicate side affected, muscle group and
  1.  ;; frequency/severity.
  1.  ;; ___ Loss of power
  1.  ;;    If checked, indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;    Indicate muscle group(s) affected (I-XXIII) if possible: _________
  1.  ;;    Indicate frequency/severity: ___ Occasional   ___ Consistent
  1.  ;;                                 ___ Consistent at a more severe level
  1.  ;; ___ Weakness
  1.  ;;    If checked, indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;    Indicate muscle group(s) affected (I-XXIII) if possible: _________
  1.  ;;    Indicate frequency/severity: ___ Occasional   ___ Consistent
  1.  ;;                                 ___ Consistent at a more severe level
  1.  ;; ___ Lowered threshold of fatigue
  1.  ;;    If checked, indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;    Indicate muscle group(s) affected (I-XXIII) if possible: _________
  1.  ;;    Indicate frequency/severity: ___ Occasional   ___ Consistent
  1.  ;;                                 ___ Consistent at a more severe level
  1.  ;; ___ Fatigue-pain
  1.  ;;    If checked, indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;    Indicate muscle group(s) affected (I-XXIII) if possible: _________
  1.  ;;    Indicate frequency/severity: ___ Occasional   ___ Consistent
  1.  ;;                                 ___ Consistent at a more severe level
  1.  ;; ___ Impairment of coordination
  1.  ;;    If checked, indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;    Indicate muscle group(s) affected (I-XXIII) if possible: _________
  1.  ;;    Indicate frequency/severity: ___ Occasional   ___ Consistent
  1.  ;;                                 ___ Consistent at a more severe level
  1.  ;; ___ Uncertainty of movement
  1.  ;;    If checked, indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;    Indicate muscle group(s) affected (I-XXIII) if possible: _________
  1.  ;;    Indicate frequency/severity: ___ Occasional   ___ Consistent
  1.  ;;                                 ___ Consistent at a more severe level
  1.  ;;
  1.  ;; If further clarification is needed due to injuries of multiple muscle groups,
  1.  ;; describe which findings, signs and/or symptoms are attributable to each
  1.  ;; muscle injury: ______________________________________________________________
  1.  ;;^TOF^
  1.  ;; 3. Muscle strength testing
  1.  ;; Test muscle strength ONLY for affected muscle groups and for the
  1.  ;; corresponding sound (non-injured) side.
  1.  ;;    Rate strength according to the following scale:
  1.  ;;       0/5 No muscle movement
  1.  ;;       1/5 Visible muscle movement, but no joint movement
  1.  ;;       2/5 No movement against gravity
  1.  ;;       3/5 No movement against resistance
  1.  ;;       4/5 Less than normal strength
  1.  ;;       5/5 Normal strength
  1.  ;;
  1.  ;; Shoulder abduction    (Group III)
  1.  ;;    Right: ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:  ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Elbow flexion         (Group V)
  1.  ;;    Right: ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:  ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Elbow extension       (Group VI)
  1.  ;;    Right: ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:  ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Wrist flexion         (Group VII)
  1.  ;;    Right: ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:  ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Wrist extension       (Group VIII)
  1.  ;;    Right: ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:  ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Hip flexion           (Group XVI)
  1.  ;;    Right: ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:  ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Knee flexion          (Group XIII)
  1.  ;;    Right: ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:  ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Knee extension        (Group XIV)
  1.  ;;    Right: ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:  ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Ankle plantar flexion (Group XI)
  1.  ;;    Right: ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:  ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; Ankle dorsiflexion    (Group XII)
  1.  ;;    Right: ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:  ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;; If other movements/muscle groups were tested, specify: ______________________
  1.  ;;    Right: ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;    Left:  ___ 5/5   ___ 4/5   ___ 3/5   ___ 2/5   ___ 1/5   ___ 0/5
  1.  ;;
  1.  ;; Does the Veteran have muscle atrophy?
  1.  ;; ___ Yes   ___ No
  1.  ;; If muscle atrophy is present, indicate location (such as calf, thigh,
  1.  ;; forearm, upper arm): _________
  1.  ;;    Indicate side affected: ___ Right   ___ Left   ___ Both
  1.  ;;    Indicate muscle group(s) affected (I-XXIII) if possible: _________________
  1.  ;; Provide measurements in centimeters of normal side and atrophied side,
  1.  ;; measured at maximum muscle bulk: 
  1.  ;;    Normal side: _____ cm.   Atrophied side: _____ cm.
  1.  ;; If muscle atrophy is present in more than one muscle group, provide location
  1.  ;; and measurements, using the same format: ____________________________________
  1.  ;;
  1.  ;; SECTION V: OTHER
  1.  ;; 1. Assistive devices
  1.  ;; a. Does the Veteran use any assistive devices as a normal mode of locomotion,
  1.  ;; although occasional locomotion by other methods may be possible?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, identify assistive devices used (check all that apply and indicate
  1.  ;; frequency):
  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.  ;; 2. Remaining effective function of the extremities
  1.  ;; Due to the Veteran's muscle conditions, is there functional impairment of an
  1.  ;; extremity such that no effective function remains other than that which would
  1.  ;; be equally well served by an amputation with prosthesis? (Functions of the
  1.  ;; upper extremity include grasping, manipulation, etc., while functions for the
  1.  ;; lower extremity include balance and propulsion, etc.)
  1.  ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
  1.  ;;     equally serve the Veteran.
  1.  ;; ___ No
  1.  ;; If yes, indicate extremities for which this applies:
  1.  ;;    ___ Right lower   ___ Right upper   ___ Left lower   ___ Left upper
  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.  ;;
  1.  ;; 3. Other pertinent physical findings, complications, conditions, signs and/or
  1.  ;; symptoms
  1.  ;; Does the Veteran have any other pertinent physical findings, complications,
  1.  ;; conditions, signs and/or symptoms?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): ___________________________________________
  1.  ;;^TOF^
  1.  ;; 4.  Diagnostic Testing
  1.  ;; NOTE: If there is reason to believe there are retained metallic fragments in
  1.  ;; the muscle tissue, appropriate x-rays are required to determine location of
  1.  ;; retained metallic fragments. Once retained metallic fragments have been 
  1.  ;; documented, further imaging studies are usually not indicated.
  1.  ;;
  1.  ;; a. Have imaging studies been performed and are the results available?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; b. Is there x-ray evidence of retained metallic fragments (such as shell
  1.  ;; fragments or shrapnel) in any muscle group?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate results: 
  1.  ;;    ___ X-ray evidence of retained shell fragment(s) and/or shrapnel
  1.  ;;        Location (specify muscle group I-XXIII, if possible): ________________
  1.  ;;        Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;;    ___ X-ray evidence of minute multiple scattered foreign bodies indicating
  1.  ;;    intermuscular trauma and explosive effect of the missile
  1.  ;;        Location (specify muscle group I-XXIII, if possible): ________________
  1.  ;;        Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; c. Were electrodiagnostic tests done?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, was there diminished muscle excitability to pulsed electrical current?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If yes, name affected muscle(s) _________________
  1.  ;;
  1.  ;; d. 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.  ;; 5. Functional impact
  1.  ;; Does the Veteran's muscle injury(ies) impact his or her ability to work, such
  1.  ;; as resulting in inability to keep up with work requirements due to muscle
  1.  ;; injury(ies)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe the impact of each of the Veteran's muscle injuries
  1.  ;; providing one or more examples: _____________________________________________
  1.  ;;
  1.  ;; 6. Remarks, if any:  ________________________________________________________
  1.  ;;
  1.  ;; Physician signature: ___________________________________________
  1.  ;; Physician printed name: ________________________________________ 
  1.  ;; Medical license #: ____________________   Date: ________________
  1.  ;; Physician address: _____________________________________________ 
  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 application.
  1.  ;;^END^
  1.  Q