DVBCQMI3 ;;ALB-CIOFO/SBW - MUSCLE INJURIES QUESTIONNAIRE ; 20/JUNE/2011
;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
;
TXT ;
;;^TOF^
;; 2. Cardinal signs and symptoms of muscle disability
;; Does the Veteran have any of the following signs and/or symptoms attributable
;; to any muscle injuries?
;; ___ Yes ___ No
;; If yes, check all that apply, and indicate side affected, muscle group and
;; frequency/severity.
;; ___ Loss of power
;; If checked, indicate side affected: ___ Right ___ Left ___ Both
;; Indicate muscle group(s) affected (I-XXIII) if possible: _________
;; Indicate frequency/severity: ___ Occasional ___ Consistent
;; ___ Consistent at a more severe level
;; ___ Weakness
;; If checked, indicate side affected: ___ Right ___ Left ___ Both
;; Indicate muscle group(s) affected (I-XXIII) if possible: _________
;; Indicate frequency/severity: ___ Occasional ___ Consistent
;; ___ Consistent at a more severe level
;; ___ Lowered threshold of fatigue
;; If checked, indicate side affected: ___ Right ___ Left ___ Both
;; Indicate muscle group(s) affected (I-XXIII) if possible: _________
;; Indicate frequency/severity: ___ Occasional ___ Consistent
;; ___ Consistent at a more severe level
;; ___ Fatigue-pain
;; If checked, indicate side affected: ___ Right ___ Left ___ Both
;; Indicate muscle group(s) affected (I-XXIII) if possible: _________
;; Indicate frequency/severity: ___ Occasional ___ Consistent
;; ___ Consistent at a more severe level
;; ___ Impairment of coordination
;; If checked, indicate side affected: ___ Right ___ Left ___ Both
;; Indicate muscle group(s) affected (I-XXIII) if possible: _________
;; Indicate frequency/severity: ___ Occasional ___ Consistent
;; ___ Consistent at a more severe level
;; ___ Uncertainty of movement
;; If checked, indicate side affected: ___ Right ___ Left ___ Both
;; Indicate muscle group(s) affected (I-XXIII) if possible: _________
;; Indicate frequency/severity: ___ Occasional ___ Consistent
;; ___ Consistent at a more severe level
;;
;; If further clarification is needed due to injuries of multiple muscle groups,
;; describe which findings, signs and/or symptoms are attributable to each
;; muscle injury: ______________________________________________________________
;;^TOF^
;; 3. Muscle strength testing
;; Test muscle strength ONLY for affected muscle groups and for the
;; corresponding sound (non-injured) side.
;; Rate strength according to the following scale:
;; 0/5 No muscle movement
;; 1/5 Visible muscle movement, but no joint movement
;; 2/5 No movement against gravity
;; 3/5 No movement against resistance
;; 4/5 Less than normal strength
;; 5/5 Normal strength
;;
;; Shoulder abduction (Group III)
;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Elbow flexion (Group V)
;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Elbow extension (Group VI)
;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Wrist flexion (Group VII)
;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Wrist extension (Group VIII)
;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Hip flexion (Group XVI)
;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Knee flexion (Group XIII)
;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Knee extension (Group XIV)
;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Ankle plantar flexion (Group XI)
;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Ankle dorsiflexion (Group XII)
;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; If other movements/muscle groups were tested, specify: ______________________
;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
;;
;; Does the Veteran have muscle atrophy?
;; ___ Yes ___ No
;; If muscle atrophy is present, indicate location (such as calf, thigh,
;; forearm, upper arm): _________
;; Indicate side affected: ___ Right ___ Left ___ Both
;; Indicate muscle group(s) affected (I-XXIII) if possible: _________________
;; Provide measurements in centimeters of normal side and atrophied side,
;; measured at maximum muscle bulk:
;; Normal side: _____ cm. Atrophied side: _____ cm.
;; If muscle atrophy is present in more than one muscle group, provide location
;; and measurements, using the same format: ____________________________________
;;
;; SECTION V: OTHER
;; 1. Assistive devices
;; a. Does the Veteran use any assistive devices as a normal mode of locomotion,
;; although occasional locomotion by other methods may be possible?
;; ___ Yes ___ No
;; If yes, identify assistive devices 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: ______________________
;; _____________________________________________________________________________
;;
;; 2. Remaining effective function of the extremities
;; Due to the Veteran's muscle conditions, 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 extremities for which this applies:
;; ___ Right lower ___ Right upper ___ Left lower ___ Left upper
;; For each checked extremity, identify the condition causing loss of
;; function, describe loss of effective function and provide specific
;; examples (brief summary): _____________________________________________
;;
;; 3. Other pertinent physical findings, complications, conditions, signs and/or
;; symptoms
;; Does the Veteran have any other pertinent physical findings, complications,
;; conditions, signs and/or symptoms?
;; ___ Yes ___ No
;; If yes, describe (brief summary): ___________________________________________
;;^TOF^
;; 4. Diagnostic Testing
;; NOTE: If there is reason to believe there are retained metallic fragments in
;; the muscle tissue, appropriate x-rays are required to determine location of
;; retained metallic fragments. Once retained metallic fragments have been
;; documented, further imaging studies are usually not indicated.
;;
;; a. Have imaging studies been performed and are the results available?
;; ___ Yes ___ No
;;
;; b. Is there x-ray evidence of retained metallic fragments (such as shell
;; fragments or shrapnel) in any muscle group?
;; ___ Yes ___ No
;; If yes, indicate results:
;; ___ X-ray evidence of retained shell fragment(s) and/or shrapnel
;; Location (specify muscle group I-XXIII, if possible): ________________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; ___ X-ray evidence of minute multiple scattered foreign bodies indicating
;; intermuscular trauma and explosive effect of the missile
;; Location (specify muscle group I-XXIII, if possible): ________________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; c. Were electrodiagnostic tests done?
;; ___ Yes ___ No
;; If yes, was there diminished muscle excitability to pulsed electrical current?
;; ___ Yes ___ No
;; If yes, name affected muscle(s) _________________
;;
;; d. 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):
;; ____________________________________________________________________________
;;
;; 5. Functional impact
;; Does the Veteran's muscle injury(ies) impact his or her ability to work, such
;; as resulting in inability to keep up with work requirements due to muscle
;; injury(ies)?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's muscle injuries
;; providing one or more examples: _____________________________________________
;;
;; 6. Remarks, if any: ________________________________________________________
;;
;; Physician signature: ___________________________________________
;; Physician printed name: ________________________________________
;; Medical license #: ____________________ Date: ________________
;; 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[HDVBCQMI3 10928 printed Dec 13, 2024@01:47:13 Page 2
DVBCQMI3 ;;ALB-CIOFO/SBW - MUSCLE INJURIES QUESTIONNAIRE ; 20/JUNE/2011
+1 ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;;^TOF^
+2 ;; 2. Cardinal signs and symptoms of muscle disability
+3 ;; Does the Veteran have any of the following signs and/or symptoms attributable
+4 ;; to any muscle injuries?
+5 ;; ___ Yes ___ No
+6 ;; If yes, check all that apply, and indicate side affected, muscle group and
+7 ;; frequency/severity.
+8 ;; ___ Loss of power
+9 ;; If checked, indicate side affected: ___ Right ___ Left ___ Both
+10 ;; Indicate muscle group(s) affected (I-XXIII) if possible: _________
+11 ;; Indicate frequency/severity: ___ Occasional ___ Consistent
+12 ;; ___ Consistent at a more severe level
+13 ;; ___ Weakness
+14 ;; If checked, indicate side affected: ___ Right ___ Left ___ Both
+15 ;; Indicate muscle group(s) affected (I-XXIII) if possible: _________
+16 ;; Indicate frequency/severity: ___ Occasional ___ Consistent
+17 ;; ___ Consistent at a more severe level
+18 ;; ___ Lowered threshold of fatigue
+19 ;; If checked, indicate side affected: ___ Right ___ Left ___ Both
+20 ;; Indicate muscle group(s) affected (I-XXIII) if possible: _________
+21 ;; Indicate frequency/severity: ___ Occasional ___ Consistent
+22 ;; ___ Consistent at a more severe level
+23 ;; ___ Fatigue-pain
+24 ;; If checked, indicate side affected: ___ Right ___ Left ___ Both
+25 ;; Indicate muscle group(s) affected (I-XXIII) if possible: _________
+26 ;; Indicate frequency/severity: ___ Occasional ___ Consistent
+27 ;; ___ Consistent at a more severe level
+28 ;; ___ Impairment of coordination
+29 ;; If checked, indicate side affected: ___ Right ___ Left ___ Both
+30 ;; Indicate muscle group(s) affected (I-XXIII) if possible: _________
+31 ;; Indicate frequency/severity: ___ Occasional ___ Consistent
+32 ;; ___ Consistent at a more severe level
+33 ;; ___ Uncertainty of movement
+34 ;; If checked, indicate side affected: ___ Right ___ Left ___ Both
+35 ;; Indicate muscle group(s) affected (I-XXIII) if possible: _________
+36 ;; Indicate frequency/severity: ___ Occasional ___ Consistent
+37 ;; ___ Consistent at a more severe level
+38 ;;
+39 ;; If further clarification is needed due to injuries of multiple muscle groups,
+40 ;; describe which findings, signs and/or symptoms are attributable to each
+41 ;; muscle injury: ______________________________________________________________
+42 ;;^TOF^
+43 ;; 3. Muscle strength testing
+44 ;; Test muscle strength ONLY for affected muscle groups and for the
+45 ;; corresponding sound (non-injured) side.
+46 ;; Rate strength according to the following scale:
+47 ;; 0/5 No muscle movement
+48 ;; 1/5 Visible muscle movement, but no joint movement
+49 ;; 2/5 No movement against gravity
+50 ;; 3/5 No movement against resistance
+51 ;; 4/5 Less than normal strength
+52 ;; 5/5 Normal strength
+53 ;;
+54 ;; Shoulder abduction (Group III)
+55 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+56 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+57 ;; Elbow flexion (Group V)
+58 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+59 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+60 ;; Elbow extension (Group VI)
+61 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+62 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+63 ;; Wrist flexion (Group VII)
+64 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+65 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+66 ;; Wrist extension (Group VIII)
+67 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+68 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+69 ;; Hip flexion (Group XVI)
+70 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+71 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+72 ;; Knee flexion (Group XIII)
+73 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+74 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+75 ;; Knee extension (Group XIV)
+76 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+77 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+78 ;; Ankle plantar flexion (Group XI)
+79 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+80 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+81 ;; Ankle dorsiflexion (Group XII)
+82 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+83 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+84 ;; If other movements/muscle groups were tested, specify: ______________________
+85 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+86 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+87 ;;
+88 ;; Does the Veteran have muscle atrophy?
+89 ;; ___ Yes ___ No
+90 ;; If muscle atrophy is present, indicate location (such as calf, thigh,
+91 ;; forearm, upper arm): _________
+92 ;; Indicate side affected: ___ Right ___ Left ___ Both
+93 ;; Indicate muscle group(s) affected (I-XXIII) if possible: _________________
+94 ;; Provide measurements in centimeters of normal side and atrophied side,
+95 ;; measured at maximum muscle bulk:
+96 ;; Normal side: _____ cm. Atrophied side: _____ cm.
+97 ;; If muscle atrophy is present in more than one muscle group, provide location
+98 ;; and measurements, using the same format: ____________________________________
+99 ;;
+100 ;; SECTION V: OTHER
+101 ;; 1. Assistive devices
+102 ;; a. Does the Veteran use any assistive devices as a normal mode of locomotion,
+103 ;; although occasional locomotion by other methods may be possible?
+104 ;; ___ Yes ___ No
+105 ;; If yes, identify assistive devices used (check all that apply and indicate
+106 ;; frequency):
+107 ;; ___Wheelchair Frequency of use: ___Occasional ___Regular ___Constant
+108 ;; ___Brace(s) Frequency of use: ___Occasional ___Regular ___Constant
+109 ;; ___Crutch(es) Frequency of use: ___Occasional ___Regular ___Constant
+110 ;; ___Cane(s) Frequency of use: ___Occasional ___Regular ___Constant
+111 ;; ___Walker Frequency of use: ___Occasional ___Regular ___Constant
+112 ;; ___Other: __________________________________________
+113 ;; Frequency of use: ___Occasional ___Regular ___Constant
+114 ;;
+115 ;; b. If the Veteran uses any assistive devices, specify the condition and
+116 ;; identify the assistive device used for each condition: ______________________
+117 ;; _____________________________________________________________________________
+118 ;;
+119 ;; 2. Remaining effective function of the extremities
+120 ;; Due to the Veteran's muscle conditions, is there functional impairment of an
+121 ;; extremity such that no effective function remains other than that which would
+122 ;; be equally well served by an amputation with prosthesis? (Functions of the
+123 ;; upper extremity include grasping, manipulation, etc., while functions for the
+124 ;; lower extremity include balance and propulsion, etc.)
+125 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+126 ;; equally serve the Veteran.
+127 ;; ___ No
+128 ;; If yes, indicate extremities for which this applies:
+129 ;; ___ Right lower ___ Right upper ___ Left lower ___ Left upper
+130 ;; For each checked extremity, identify the condition causing loss of
+131 ;; function, describe loss of effective function and provide specific
+132 ;; examples (brief summary): _____________________________________________
+133 ;;
+134 ;; 3. Other pertinent physical findings, complications, conditions, signs and/or
+135 ;; symptoms
+136 ;; Does the Veteran have any other pertinent physical findings, complications,
+137 ;; conditions, signs and/or symptoms?
+138 ;; ___ Yes ___ No
+139 ;; If yes, describe (brief summary): ___________________________________________
+140 ;;^TOF^
+141 ;; 4. Diagnostic Testing
+142 ;; NOTE: If there is reason to believe there are retained metallic fragments in
+143 ;; the muscle tissue, appropriate x-rays are required to determine location of
+144 ;; retained metallic fragments. Once retained metallic fragments have been
+145 ;; documented, further imaging studies are usually not indicated.
+146 ;;
+147 ;; a. Have imaging studies been performed and are the results available?
+148 ;; ___ Yes ___ No
+149 ;;
+150 ;; b. Is there x-ray evidence of retained metallic fragments (such as shell
+151 ;; fragments or shrapnel) in any muscle group?
+152 ;; ___ Yes ___ No
+153 ;; If yes, indicate results:
+154 ;; ___ X-ray evidence of retained shell fragment(s) and/or shrapnel
+155 ;; Location (specify muscle group I-XXIII, if possible): ________________
+156 ;; Side affected: ___ Right ___ Left ___ Both
+157 ;;
+158 ;; ___ X-ray evidence of minute multiple scattered foreign bodies indicating
+159 ;; intermuscular trauma and explosive effect of the missile
+160 ;; Location (specify muscle group I-XXIII, if possible): ________________
+161 ;; Side affected: ___ Right ___ Left ___ Both
+162 ;;
+163 ;; c. Were electrodiagnostic tests done?
+164 ;; ___ Yes ___ No
+165 ;; If yes, was there diminished muscle excitability to pulsed electrical current?
+166 ;; ___ Yes ___ No
+167 ;; If yes, name affected muscle(s) _________________
+168 ;;
+169 ;; d. Are there any other significant diagnostic test findings and/or results?
+170 ;; ___ Yes ___ No
+171 ;; If yes, provide type of test or procedure, date and results (brief summary):
+172 ;; ____________________________________________________________________________
+173 ;;
+174 ;; 5. Functional impact
+175 ;; Does the Veteran's muscle injury(ies) impact his or her ability to work, such
+176 ;; as resulting in inability to keep up with work requirements due to muscle
+177 ;; injury(ies)?
+178 ;; ___ Yes ___ No
+179 ;; If yes, describe the impact of each of the Veteran's muscle injuries
+180 ;; providing one or more examples: _____________________________________________
+181 ;;
+182 ;; 6. Remarks, if any: ________________________________________________________
+183 ;;
+184 ;; Physician signature: ___________________________________________
+185 ;; Physician printed name: ________________________________________
+186 ;; Medical license #: ____________________ Date: ________________
+187 ;; Physician address: _____________________________________________
+188 ;; Phone: ____________________________ Fax: _____________________________
+189 ;;
+190 ;; NOTE: VA may request additional medical information, including additional
+191 ;; examinations if necessary to complete VA's review of the Veteran's application.
+192 ;;^END^
+193 QUIT
