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Routine: DVBCQMS2

DVBCQMS2.m

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  1. DVBCQMS2 ;;ALB-CIOFO/ECF - MULTIPLE SCLEROSIS QUESTIONNAIRE ; 5/10/2011
  1.  ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA)
  1.  ;; for disability benefits.  VA will consider the information you provide on
  1.  ;; this questionnaire as part of their evaluation in processing the Veteran's
  1.  ;; claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;;
  1.  ;; Does the Veteran have multiple sclerosis (MS)?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide only diagnoses that pertain to MS:
  1.  ;; Diagnosis #1: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;;
  1.  ;; Diagnosis #2: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;;
  1.  ;; Diagnosis #3: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to MS, list using above
  1.  ;; format: ____________________________________________________________________
  1.  ;;
  1.  ;;2. Medical history
  1.  ;;
  1.  ;; a. Describe the history (including onset and course) of the Veteran's MS
  1.  ;; (brief summary): ___________________________________________________________
  1.  ;;
  1.  ;; b. Dominant hand
  1.  ;; ___ Right   ___ Left   ___ Ambidextrous
  1.  ;;
  1.  ;; 3. Conditions, signs and symptoms due to MS
  1.  ;;
  1.  ;; a. Does the Veteran have any muscle weakness in the upper and/or lower
  1.  ;; extremities attributable to MS?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, report under strength testing in neurologic exam section.
  1.  ;;^TOF^
  1.  ;; b. Does the Veteran have any pharynx and/or larynx and/or swallowing
  1.  ;; conditions due to MS?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Constant inability to communicate by speech
  1.  ;;    ___ Speech not intelligible or individual is aphonic
  1.  ;;    ___ Paralysis of soft palate with swallowing difficulty (nasal
  1.  ;;        regurgitation) and speech impairment
  1.  ;;    ___ Hoarseness
  1.  ;;    ___ Mild swallowing difficulties
  1.  ;;    ___ Moderate swallowing difficulties
  1.  ;;    ___ Severe swallowing difficulties, permitting passage of liquids only
  1.  ;;    ___ Requires feeding tube due to swallowing difficulties
  1.  ;;    ___ Other, describe: ______________________
  1.  ;;
  1.  ;; c. Does the Veteran have any respiratory conditions attributable to MS?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide PFT results under "Diagnostic testing" section and complete
  1.  ;; Respiratory Questionnaire (DBQ).
  1.  ;;
  1.  ;; d. Does the Veteran have sleep disturbances attributable to MS?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Insomnia
  1.  ;;    ___ Hypersomnolence and/or daytime "sleep attacks"
  1.  ;;    ___ Persistent daytime hypersomnolence
  1.  ;;    ___ Sleep apnea requiring the use of breathing assistance device such as
  1.  ;;        continuous airway pressure (CPAP) machine
  1.  ;;    ___ Sleep apnea causing chronic respiratory failure with carbon dioxide
  1.  ;;        retention or cor pulmonale
  1.  ;;    ___ Sleep apnea requiring tracheostomy
  1.  ;;
  1.  ;; e. Does the Veteran have any bowel functional impairment attributable to MS?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Slight impairment of sphincter control, without leakage
  1.  ;;    ___ Constant slight leakage
  1.  ;;    ___ Occasional moderate leakage
  1.  ;;    ___ Occasional involuntary bowel movements, necessitating wearing of
  1.  ;;        a pad
  1.  ;;    ___ Extensive leakage and fairly frequent involuntary bowel movements
  1.  ;;    ___ Total loss of bowel sphincter control
  1.  ;;    ___ Chronic constipation
  1.  ;;    ___ Other bowel impairment (describe): __________________________________
  1.  ;;^TOF^
  1.  ;; f. Does the Veteran have voiding dysfunction causing urine leakage
  1.  ;; attributable to MS?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Does not require/does not use absorbent material
  1.  ;;    ___ Requires absorbent material that is changed less than 2 times per day
  1.  ;;    ___ Requires absorbent material that is changed 2 to 4 times per day
  1.  ;;    ___ Requires absorbent material that is changed more than 4 times per day
  1.  ;;
  1.  ;; g. Does the Veteran have voiding dysfunction causing urinary frequency
  1.  ;; attributable to MS?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, check all that apply:
  1.  ;;    ___ Daytime voiding interval between 2 and 3 hours
  1.  ;;    ___ Daytime voiding interval between 1 and 2 hours
  1.  ;;    ___ Daytime voiding interval less than 1 hour
  1.  ;;    ___ Nighttime awakening to void 2 times
  1.  ;;    ___ Nighttime awakening to void 3 to 4 times
  1.  ;;    ___ Nighttime awakening to void 5 or more times
  1.  ;;
  1.  ;; h. Does the Veteran have voiding dysfunction causing obstructed voiding
  1.  ;; attributable to MS?
  1.  ;; ___ Yes ___ No
  1.  ;; If yes, check all signs and symptoms that apply:
  1.  ;;    ___ Hesitancy
  1.  ;;        If checked, is hesitancy marked?
  1.  ;;        ___ Yes   ___ No
  1.  ;;    ___ Slow or weak stream
  1.  ;;        If checked, is stream markedly slow or weak?
  1.  ;;        ___ Yes   ___ No
  1.  ;;    ___ Decreased force of stream
  1.  ;;        If checked, is force of stream markedly decreased?
  1.  ;;        ___ Yes   ___ No
  1.  ;;    ___ Stricture disease requiring dilatation 1 to 2 times per year
  1.  ;;    ___ Stricture disease requiring periodic dilatation every 2 to 3 months
  1.  ;;    ___ Recurrent urinary tract infections secondary to obstruction
  1.  ;;    ___ Uroflowmetry peak flow rate less than 10 cc/sec
  1.  ;;    ___ Post void residuals greater than 150 cc
  1.  ;;    ___ Urinary retention requiring intermittent or continuous
  1.  ;;        catheterization
  1.  ;;
  1.  ;; i. Does the Veteran have voiding dysfunction requiring the use of an
  1.  ;; appliance attributable to MS?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe: __________________________________________________________
  1.  ;;^TOF^
  1.  ;; j. Does the Veteran have a history of recurrent symptomatic urinary tract
  1.  ;; infections attributable to MS?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all treatments that apply:
  1.  ;; ___ No treatment
  1.  ;; ___ Long-term drug therapy
  1.  ;;     If checked, list medications used for urinary tract infection and
  1.  ;;     indicate dates for courses of treatment over the past 12 months: _______
  1.  ;; ___ Hospitalization
  1.  ;;     If checked, indicate frequency of hospitalization:
  1.  ;;     ___ 1 or 2 per year
  1.  ;;     ___ More than 2 per year
  1.  ;; ___ Drainage
  1.  ;;     If checked, indicate dates when drainage performed over past 12 months:
  1.  ;;     ________________________________________________________________________
  1.  ;; ___ Other management/treatment not listed above
  1.  ;;     Description of management/treatment including dates of treatment:
  1.  ;;     ________________________________________________________________________
  1.  ;;
  1.  ;; k. Does the Veteran (if male) have erectile dysfunction attributable to MS?
  1.  ;; ___ Yes   ___ No
  1.  ;;     If yes, is the Veteran able to achieve an erection (without medication)
  1.  ;;     sufficient for penetration and ejaculation?
  1.  ;;     ___ Yes   ___ No
  1.  ;;               If no, is the Veteran able to achieve an erection (with
  1.  ;;               medication) sufficient for penetration and ejaculation?
  1.  ;;               ___ Yes   ___ No
  1.  ;;
  1.  ;; l. Visual disturbances
  1.  ;; Does the Veteran have any visual disturbances attributable to MS?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, check all that apply, and also complete Eye Questionnaire (schedule
  1.  ;; with appropriate examiner):
  1.  ;;    ___ Diplopia
  1.  ;;    ___ Blurring of vision
  1.  ;;    ___ Internuclear ophthalmoplegia
  1.  ;;    ___ Decreased visual acuity
  1.  ;;        If checked, specify: ___ unilateral    ___ bilateral
  1.  ;;    ___ Visual scotoma
  1.  ;;        If checked, specify: ___ unilateral    ___ bilateral
  1.  ;;    ___ Nystagmus
  1.  ;;    ___ Optic neuritis
  1.  ;;    ___ Other, describe: ____________________________________________________
  1.  ;;^TOF^
  1.  ;; 4. Neurologic exam
  1.  ;;
  1.  ;; a. Gait
  1.  ;; ___ Normal  ___ Abnormal, describe: ________________________________________
  1.  ;; If gait is abnormal, and the Veteran has more than one medical condition
  1.  ;; contributing to the abnormal gait, identify the conditions and describe each
  1.  ;; condition's contribution to the abnormal gait: _____________________________
  1.  ;;
  1.  ;; b. Strength
  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.  ;;___ All Normal
  1.  ;; Shoulder extension:
  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.  ;; Shoulder flexion:
  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:
  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:
  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:
  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:
  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.  ;; Grip:
  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.  ;; Pinch (thumb to index finger):
  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 extension:
  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:
  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.  ;;^TOF^
  1.  ;; Knee extension:
  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:
  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:
  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.  ;; If there are other weaknesses, please specify using the above format:
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; c. Deep tendon reflexes (DTRs)
  1.  ;; Rate reflexes according to the following scale:
  1.  ;;    0  Absent
  1.  ;;    1+ Decreased
  1.  ;;    2+ Normal
  1.  ;;    3+ Increased without clonus
  1.  ;;    4+ Increased with clonus
  1.  ;;
  1.  ;; ___ All Normal
  1.  ;; Biceps:  Right: ___ 0   ___ 1+  ___ 2+  ___ 3+  ___ 4+
  1.  ;;          Left:  ___ 0   ___ 1+  ___ 2+  ___ 3+  ___ 4+
  1.  ;; Triceps: Right: ___ 0   ___ 1+  ___ 2+  ___ 3+  ___ 4+
  1.  ;;          Left:  ___ 0   ___ 1+  ___ 2+  ___ 3+  ___ 4+
  1.  ;; Brachioradialis:
  1.  ;;          Right: ___ 0   ___ 1+  ___ 2+  ___ 3+  ___ 4+
  1.  ;;          Left:  ___ 0   ___ 1+  ___ 2+  ___ 3+  ___ 4+
  1.  ;; Knee:    Right: ___ 0   ___ 1+  ___ 2+  ___ 3+  ___ 4+
  1.  ;;          Left:  ___ 0   ___ 1+  ___ 2+  ___ 3+  ___ 4+
  1.  ;; Ankle:   Right: ___ 0   ___ 1+  ___ 2+  ___ 3+  ___ 4+
  1.  ;;          Left:  ___ 0   ___ 1+  ___ 2+  ___ 3+  ___ 4+
  1.  ;;
  1.  ;; d. Sensation testing results:
  1.  ;;
  1.  ;; ___ All Normal
  1.  ;; Shoulder area (C5):  Right:  ___ Normal  ___ Decreased  ___ Absent
  1.  ;;                      Left:   ___ Normal  ___ Decreased  ___ Absent
  1.  ;; Inner/outer forearm (C6/T1):
  1.  ;;                      Right:  ___ Normal  ___ Decreased  ___ Absent
  1.  ;;                      Left:   ___ Normal  ___ Decreased  ___ Absent
  1.  ;; Hand/fingers (C6-8): Right:  ___ Normal  ___ Decreased  ___ Absent
  1.  ;;                      Left:   ___ Normal  ___ Decreased  ___ Absent
  1.  ;; Thorax:
  1.  ;;   Anterior:          Right:  ___ Normal  ___ Decreased  ___ Absent
  1.  ;;                      Left:   ___ Normal  ___ Decreased  ___ Absent
  1.  ;;   Posterior:         Right:  ___ Normal  ___ Decreased  ___ Absent
  1.  ;;                      Left:   ___ Normal  ___ Decreased  ___ Absent
  1.  ;;^TOF^
  1.  ;; Trunk:
  1.  ;;   Anterior:          Right:  ___ Normal  ___ Decreased  ___ Absent
  1.  ;;                      Left:   ___ Normal  ___ Decreased  ___ Absent
  1.  ;;   Posterior:         Right:  ___ Normal  ___ Decreased  ___ Absent
  1.  ;;                      Left:   ___ Normal  ___ Decreased  ___ Absent
  1.  ;; Thigh/knee (L3/4):   Right:  ___ Normal  ___ Decreased  ___ Absent
  1.  ;;                      Left:   ___ Normal  ___ Decreased  ___ Absent
  1.  ;; Lower leg/ankle (L4/L5/S1):
  1.  ;;                      Right:  ___ Normal  ___ Decreased  ___ Absent
  1.  ;;                      Left:   ___ Normal  ___ Decreased  ___ Absent
  1.  ;; Foot/toes (L5):      Right:  ___ Normal  ___ Decreased  ___ Absent
  1.  ;;                      Left:   ___ Normal  ___ Decreased  ___ Absent
  1.  ;; 
  1.  ;; e. Does the Veteran have muscle atrophy attributable to MS?
  1.  ;; ___ Yes   ___ No
  1.  ;; If muscle atrophy is present, indicate location: ___________________________
  1.  ;; When possible, provide difference measured in cm between normal and
  1.  ;; atrophied side, measured at maximum muscle bulk: _____ cm.
  1.  ;;
  1.  ;; f. Summary of muscle weakness in the upper and/or lower extremities
  1.  ;; attributable to MS (check all that apply):
  1.  ;; Right upper extremity muscle weakness:
  1.  ;; ___ None___ Mild___ Moderate___ Severe
  1.  ;; ___ With atrophy ___ Complete (no remaining function)
  1.  ;; Left upper extremity muscle weakness:
  1.  ;; ___ None___ Mild___ Moderate___ Severe
  1.  ;; ___ With atrophy ___ Complete (no remaining function)
  1.  ;; Right lower extremity muscle weakness:
  1.  ;; ___ None___ Mild___ Moderate___ Severe
  1.  ;; ___ With atrophy ___ Complete (no remaining function)
  1.  ;; Left lower extremity muscle weakness:
  1.  ;; ___ None___ Mild___ Moderate___ Severe
  1.  ;; ___ With atrophy ___ Complete (no remaining function)
  1.  ;; NOTE: If the Veteran has more than one medical condition contributing to the
  1.  ;; muscle weakness, identify the condition(s) and describe each condition's
  1.  ;; contribution to the muscle weakness: _______________________________________
  1.  ;;
  1.  Q