DVBCQMS2 ;;ALB-CIOFO/ECF - MULTIPLE SCLEROSIS QUESTIONNAIRE ; 5/10/2011
;;2.7;AMIE;**174**;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.
;;
;; 1. Diagnosis
;;
;; Does the Veteran have multiple sclerosis (MS)?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to MS:
;; Diagnosis #1: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;;
;; Diagnosis #2: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;;
;; Diagnosis #3: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;;
;; If there are additional diagnoses that pertain to MS, list using above
;; format: ____________________________________________________________________
;;
;;2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's MS
;; (brief summary): ___________________________________________________________
;;
;; b. Dominant hand
;; ___ Right ___ Left ___ Ambidextrous
;;
;; 3. Conditions, signs and symptoms due to MS
;;
;; a. Does the Veteran have any muscle weakness in the upper and/or lower
;; extremities attributable to MS?
;; ___ Yes ___ No
;; If yes, report under strength testing in neurologic exam section.
;;^TOF^
;; b. Does the Veteran have any pharynx and/or larynx and/or swallowing
;; conditions due to MS?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Constant inability to communicate by speech
;; ___ Speech not intelligible or individual is aphonic
;; ___ Paralysis of soft palate with swallowing difficulty (nasal
;; regurgitation) and speech impairment
;; ___ Hoarseness
;; ___ Mild swallowing difficulties
;; ___ Moderate swallowing difficulties
;; ___ Severe swallowing difficulties, permitting passage of liquids only
;; ___ Requires feeding tube due to swallowing difficulties
;; ___ Other, describe: ______________________
;;
;; c. Does the Veteran have any respiratory conditions attributable to MS?
;; ___ Yes ___ No
;; If yes, provide PFT results under "Diagnostic testing" section and complete
;; Respiratory Questionnaire (DBQ).
;;
;; d. Does the Veteran have sleep disturbances attributable to MS?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Insomnia
;; ___ Hypersomnolence and/or daytime "sleep attacks"
;; ___ Persistent daytime hypersomnolence
;; ___ Sleep apnea requiring the use of breathing assistance device such as
;; continuous airway pressure (CPAP) machine
;; ___ Sleep apnea causing chronic respiratory failure with carbon dioxide
;; retention or cor pulmonale
;; ___ Sleep apnea requiring tracheostomy
;;
;; e. Does the Veteran have any bowel functional impairment attributable to MS?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Slight impairment of sphincter control, without leakage
;; ___ Constant slight leakage
;; ___ Occasional moderate leakage
;; ___ Occasional involuntary bowel movements, necessitating wearing of
;; a pad
;; ___ Extensive leakage and fairly frequent involuntary bowel movements
;; ___ Total loss of bowel sphincter control
;; ___ Chronic constipation
;; ___ Other bowel impairment (describe): __________________________________
;;^TOF^
;; f. Does the Veteran have voiding dysfunction causing urine leakage
;; attributable to MS?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Does not require/does not use absorbent material
;; ___ Requires absorbent material that is changed less than 2 times per day
;; ___ Requires absorbent material that is changed 2 to 4 times per day
;; ___ Requires absorbent material that is changed more than 4 times per day
;;
;; g. Does the Veteran have voiding dysfunction causing urinary frequency
;; attributable to MS?
;; ___ Yes ___ No
;; If yes, check all that apply:
;; ___ Daytime voiding interval between 2 and 3 hours
;; ___ Daytime voiding interval between 1 and 2 hours
;; ___ Daytime voiding interval less than 1 hour
;; ___ Nighttime awakening to void 2 times
;; ___ Nighttime awakening to void 3 to 4 times
;; ___ Nighttime awakening to void 5 or more times
;;
;; h. Does the Veteran have voiding dysfunction causing obstructed voiding
;; attributable to MS?
;; ___ Yes ___ No
;; If yes, check all signs and symptoms that apply:
;; ___ Hesitancy
;; If checked, is hesitancy marked?
;; ___ Yes ___ No
;; ___ Slow or weak stream
;; If checked, is stream markedly slow or weak?
;; ___ Yes ___ No
;; ___ Decreased force of stream
;; If checked, is force of stream markedly decreased?
;; ___ Yes ___ No
;; ___ Stricture disease requiring dilatation 1 to 2 times per year
;; ___ Stricture disease requiring periodic dilatation every 2 to 3 months
;; ___ Recurrent urinary tract infections secondary to obstruction
;; ___ Uroflowmetry peak flow rate less than 10 cc/sec
;; ___ Post void residuals greater than 150 cc
;; ___ Urinary retention requiring intermittent or continuous
;; catheterization
;;
;; i. Does the Veteran have voiding dysfunction requiring the use of an
;; appliance attributable to MS?
;; ___ Yes ___ No
;; If yes, describe: __________________________________________________________
;;^TOF^
;; j. Does the Veteran have a history of recurrent symptomatic urinary tract
;; infections attributable to MS?
;; ___ Yes ___ No
;; If yes, check all treatments that apply:
;; ___ No treatment
;; ___ Long-term drug therapy
;; If checked, list medications used for urinary tract infection and
;; indicate dates for courses of treatment over the past 12 months: _______
;; ___ Hospitalization
;; If checked, indicate frequency of hospitalization:
;; ___ 1 or 2 per year
;; ___ More than 2 per year
;; ___ Drainage
;; If checked, indicate dates when drainage performed over past 12 months:
;; ________________________________________________________________________
;; ___ Other management/treatment not listed above
;; Description of management/treatment including dates of treatment:
;; ________________________________________________________________________
;;
;; k. Does the Veteran (if male) have erectile dysfunction attributable to MS?
;; ___ Yes ___ No
;; If yes, is the Veteran able to achieve an erection (without medication)
;; sufficient for penetration and ejaculation?
;; ___ Yes ___ No
;; If no, is the Veteran able to achieve an erection (with
;; medication) sufficient for penetration and ejaculation?
;; ___ Yes ___ No
;;
;; l. Visual disturbances
;; Does the Veteran have any visual disturbances attributable to MS?
;; ___ Yes ___ No
;; If yes, check all that apply, and also complete Eye Questionnaire (schedule
;; with appropriate examiner):
;; ___ Diplopia
;; ___ Blurring of vision
;; ___ Internuclear ophthalmoplegia
;; ___ Decreased visual acuity
;; If checked, specify: ___ unilateral ___ bilateral
;; ___ Visual scotoma
;; If checked, specify: ___ unilateral ___ bilateral
;; ___ Nystagmus
;; ___ Optic neuritis
;; ___ Other, describe: ____________________________________________________
;;^TOF^
;; 4. Neurologic exam
;;
;; a. Gait
;; ___ Normal ___ Abnormal, describe: ________________________________________
;; If gait is abnormal, and the Veteran has more than one medical condition
;; contributing to the abnormal gait, identify the conditions and describe each
;; condition's contribution to the abnormal gait: _____________________________
;;
;; b. Strength
;; 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
;;
;;___ All Normal
;; Shoulder extension:
;; 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
;; Shoulder flexion:
;; 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:
;; 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:
;; 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:
;; 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:
;; 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
;; Grip:
;; 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
;; Pinch (thumb to index finger):
;; 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 extension:
;; 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:
;; 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
;;^TOF^
;; Knee extension:
;; 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:
;; 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:
;; 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 there are other weaknesses, please specify using the above format:
;; ____________________________________________________________________________
;;
;; c. Deep tendon reflexes (DTRs)
;; Rate reflexes according to the following scale:
;; 0 Absent
;; 1+ Decreased
;; 2+ Normal
;; 3+ Increased without clonus
;; 4+ Increased with clonus
;;
;; ___ All Normal
;; Biceps: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Triceps: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Brachioradialis:
;; Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Knee: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Ankle: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
;;
;; d. Sensation testing results:
;;
;; ___ All Normal
;; Shoulder area (C5): Right: ___ Normal ___ Decreased ___ Absent
;; Left: ___ Normal ___ Decreased ___ Absent
;; Inner/outer forearm (C6/T1):
;; Right: ___ Normal ___ Decreased ___ Absent
;; Left: ___ Normal ___ Decreased ___ Absent
;; Hand/fingers (C6-8): Right: ___ Normal ___ Decreased ___ Absent
;; Left: ___ Normal ___ Decreased ___ Absent
;; Thorax:
;; Anterior: Right: ___ Normal ___ Decreased ___ Absent
;; Left: ___ Normal ___ Decreased ___ Absent
;; Posterior: Right: ___ Normal ___ Decreased ___ Absent
;; Left: ___ Normal ___ Decreased ___ Absent
;;^TOF^
;; Trunk:
;; Anterior: Right: ___ Normal ___ Decreased ___ Absent
;; Left: ___ Normal ___ Decreased ___ Absent
;; Posterior: Right: ___ Normal ___ Decreased ___ Absent
;; Left: ___ Normal ___ Decreased ___ Absent
;; Thigh/knee (L3/4): Right: ___ Normal ___ Decreased ___ Absent
;; Left: ___ Normal ___ Decreased ___ Absent
;; Lower leg/ankle (L4/L5/S1):
;; Right: ___ Normal ___ Decreased ___ Absent
;; Left: ___ Normal ___ Decreased ___ Absent
;; Foot/toes (L5): Right: ___ Normal ___ Decreased ___ Absent
;; Left: ___ Normal ___ Decreased ___ Absent
;;
;; e. Does the Veteran have muscle atrophy attributable to MS?
;; ___ Yes ___ No
;; If muscle atrophy is present, indicate location: ___________________________
;; When possible, provide difference measured in cm between normal and
;; atrophied side, measured at maximum muscle bulk: _____ cm.
;;
;; f. Summary of muscle weakness in the upper and/or lower extremities
;; attributable to MS (check all that apply):
;; Right upper extremity muscle weakness:
;; ___ None___ Mild___ Moderate___ Severe
;; ___ With atrophy ___ Complete (no remaining function)
;; Left upper extremity muscle weakness:
;; ___ None___ Mild___ Moderate___ Severe
;; ___ With atrophy ___ Complete (no remaining function)
;; Right lower extremity muscle weakness:
;; ___ None___ Mild___ Moderate___ Severe
;; ___ With atrophy ___ Complete (no remaining function)
;; Left lower extremity muscle weakness:
;; ___ None___ Mild___ Moderate___ Severe
;; ___ With atrophy ___ Complete (no remaining function)
;; NOTE: If the Veteran has more than one medical condition contributing to the
;; muscle weakness, identify the condition(s) and describe each condition's
;; contribution to the muscle weakness: _______________________________________
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQMS2 14596 printed Dec 13, 2024@01:47:24 Page 2
DVBCQMS2 ;;ALB-CIOFO/ECF - MULTIPLE SCLEROSIS QUESTIONNAIRE ; 5/10/2011
+1 ;;2.7;AMIE;**174**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA)
+3 ;; for disability benefits. VA will consider the information you provide on
+4 ;; this questionnaire as part of their evaluation in processing the Veteran's
+5 ;; claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran have multiple sclerosis (MS)?
+10 ;; ___ Yes ___ No
+11 ;;
+12 ;; If yes, provide only diagnoses that pertain to MS:
+13 ;; Diagnosis #1: ___________________
+14 ;; ICD code: ______________________
+15 ;; Date of diagnosis: ______________
+16 ;;
+17 ;; Diagnosis #2: ___________________
+18 ;; ICD code: ______________________
+19 ;; Date of diagnosis: ______________
+20 ;;
+21 ;; Diagnosis #3: ___________________
+22 ;; ICD code: ______________________
+23 ;; Date of diagnosis: ______________
+24 ;;
+25 ;; If there are additional diagnoses that pertain to MS, list using above
+26 ;; format: ____________________________________________________________________
+27 ;;
+28 ;;2. Medical history
+29 ;;
+30 ;; a. Describe the history (including onset and course) of the Veteran's MS
+31 ;; (brief summary): ___________________________________________________________
+32 ;;
+33 ;; b. Dominant hand
+34 ;; ___ Right ___ Left ___ Ambidextrous
+35 ;;
+36 ;; 3. Conditions, signs and symptoms due to MS
+37 ;;
+38 ;; a. Does the Veteran have any muscle weakness in the upper and/or lower
+39 ;; extremities attributable to MS?
+40 ;; ___ Yes ___ No
+41 ;; If yes, report under strength testing in neurologic exam section.
+42 ;;^TOF^
+43 ;; b. Does the Veteran have any pharynx and/or larynx and/or swallowing
+44 ;; conditions due to MS?
+45 ;; ___ Yes ___ No
+46 ;; If yes, check all that apply:
+47 ;; ___ Constant inability to communicate by speech
+48 ;; ___ Speech not intelligible or individual is aphonic
+49 ;; ___ Paralysis of soft palate with swallowing difficulty (nasal
+50 ;; regurgitation) and speech impairment
+51 ;; ___ Hoarseness
+52 ;; ___ Mild swallowing difficulties
+53 ;; ___ Moderate swallowing difficulties
+54 ;; ___ Severe swallowing difficulties, permitting passage of liquids only
+55 ;; ___ Requires feeding tube due to swallowing difficulties
+56 ;; ___ Other, describe: ______________________
+57 ;;
+58 ;; c. Does the Veteran have any respiratory conditions attributable to MS?
+59 ;; ___ Yes ___ No
+60 ;; If yes, provide PFT results under "Diagnostic testing" section and complete
+61 ;; Respiratory Questionnaire (DBQ).
+62 ;;
+63 ;; d. Does the Veteran have sleep disturbances attributable to MS?
+64 ;; ___ Yes ___ No
+65 ;; If yes, check all that apply:
+66 ;; ___ Insomnia
+67 ;; ___ Hypersomnolence and/or daytime "sleep attacks"
+68 ;; ___ Persistent daytime hypersomnolence
+69 ;; ___ Sleep apnea requiring the use of breathing assistance device such as
+70 ;; continuous airway pressure (CPAP) machine
+71 ;; ___ Sleep apnea causing chronic respiratory failure with carbon dioxide
+72 ;; retention or cor pulmonale
+73 ;; ___ Sleep apnea requiring tracheostomy
+74 ;;
+75 ;; e. Does the Veteran have any bowel functional impairment attributable to MS?
+76 ;; ___ Yes ___ No
+77 ;; If yes, check all that apply:
+78 ;; ___ Slight impairment of sphincter control, without leakage
+79 ;; ___ Constant slight leakage
+80 ;; ___ Occasional moderate leakage
+81 ;; ___ Occasional involuntary bowel movements, necessitating wearing of
+82 ;; a pad
+83 ;; ___ Extensive leakage and fairly frequent involuntary bowel movements
+84 ;; ___ Total loss of bowel sphincter control
+85 ;; ___ Chronic constipation
+86 ;; ___ Other bowel impairment (describe): __________________________________
+87 ;;^TOF^
+88 ;; f. Does the Veteran have voiding dysfunction causing urine leakage
+89 ;; attributable to MS?
+90 ;; ___ Yes ___ No
+91 ;; If yes, check all that apply:
+92 ;; ___ Does not require/does not use absorbent material
+93 ;; ___ Requires absorbent material that is changed less than 2 times per day
+94 ;; ___ Requires absorbent material that is changed 2 to 4 times per day
+95 ;; ___ Requires absorbent material that is changed more than 4 times per day
+96 ;;
+97 ;; g. Does the Veteran have voiding dysfunction causing urinary frequency
+98 ;; attributable to MS?
+99 ;; ___ Yes ___ No
+100 ;; If yes, check all that apply:
+101 ;; ___ Daytime voiding interval between 2 and 3 hours
+102 ;; ___ Daytime voiding interval between 1 and 2 hours
+103 ;; ___ Daytime voiding interval less than 1 hour
+104 ;; ___ Nighttime awakening to void 2 times
+105 ;; ___ Nighttime awakening to void 3 to 4 times
+106 ;; ___ Nighttime awakening to void 5 or more times
+107 ;;
+108 ;; h. Does the Veteran have voiding dysfunction causing obstructed voiding
+109 ;; attributable to MS?
+110 ;; ___ Yes ___ No
+111 ;; If yes, check all signs and symptoms that apply:
+112 ;; ___ Hesitancy
+113 ;; If checked, is hesitancy marked?
+114 ;; ___ Yes ___ No
+115 ;; ___ Slow or weak stream
+116 ;; If checked, is stream markedly slow or weak?
+117 ;; ___ Yes ___ No
+118 ;; ___ Decreased force of stream
+119 ;; If checked, is force of stream markedly decreased?
+120 ;; ___ Yes ___ No
+121 ;; ___ Stricture disease requiring dilatation 1 to 2 times per year
+122 ;; ___ Stricture disease requiring periodic dilatation every 2 to 3 months
+123 ;; ___ Recurrent urinary tract infections secondary to obstruction
+124 ;; ___ Uroflowmetry peak flow rate less than 10 cc/sec
+125 ;; ___ Post void residuals greater than 150 cc
+126 ;; ___ Urinary retention requiring intermittent or continuous
+127 ;; catheterization
+128 ;;
+129 ;; i. Does the Veteran have voiding dysfunction requiring the use of an
+130 ;; appliance attributable to MS?
+131 ;; ___ Yes ___ No
+132 ;; If yes, describe: __________________________________________________________
+133 ;;^TOF^
+134 ;; j. Does the Veteran have a history of recurrent symptomatic urinary tract
+135 ;; infections attributable to MS?
+136 ;; ___ Yes ___ No
+137 ;; If yes, check all treatments that apply:
+138 ;; ___ No treatment
+139 ;; ___ Long-term drug therapy
+140 ;; If checked, list medications used for urinary tract infection and
+141 ;; indicate dates for courses of treatment over the past 12 months: _______
+142 ;; ___ Hospitalization
+143 ;; If checked, indicate frequency of hospitalization:
+144 ;; ___ 1 or 2 per year
+145 ;; ___ More than 2 per year
+146 ;; ___ Drainage
+147 ;; If checked, indicate dates when drainage performed over past 12 months:
+148 ;; ________________________________________________________________________
+149 ;; ___ Other management/treatment not listed above
+150 ;; Description of management/treatment including dates of treatment:
+151 ;; ________________________________________________________________________
+152 ;;
+153 ;; k. Does the Veteran (if male) have erectile dysfunction attributable to MS?
+154 ;; ___ Yes ___ No
+155 ;; If yes, is the Veteran able to achieve an erection (without medication)
+156 ;; sufficient for penetration and ejaculation?
+157 ;; ___ Yes ___ No
+158 ;; If no, is the Veteran able to achieve an erection (with
+159 ;; medication) sufficient for penetration and ejaculation?
+160 ;; ___ Yes ___ No
+161 ;;
+162 ;; l. Visual disturbances
+163 ;; Does the Veteran have any visual disturbances attributable to MS?
+164 ;; ___ Yes ___ No
+165 ;; If yes, check all that apply, and also complete Eye Questionnaire (schedule
+166 ;; with appropriate examiner):
+167 ;; ___ Diplopia
+168 ;; ___ Blurring of vision
+169 ;; ___ Internuclear ophthalmoplegia
+170 ;; ___ Decreased visual acuity
+171 ;; If checked, specify: ___ unilateral ___ bilateral
+172 ;; ___ Visual scotoma
+173 ;; If checked, specify: ___ unilateral ___ bilateral
+174 ;; ___ Nystagmus
+175 ;; ___ Optic neuritis
+176 ;; ___ Other, describe: ____________________________________________________
+177 ;;^TOF^
+178 ;; 4. Neurologic exam
+179 ;;
+180 ;; a. Gait
+181 ;; ___ Normal ___ Abnormal, describe: ________________________________________
+182 ;; If gait is abnormal, and the Veteran has more than one medical condition
+183 ;; contributing to the abnormal gait, identify the conditions and describe each
+184 ;; condition's contribution to the abnormal gait: _____________________________
+185 ;;
+186 ;; b. Strength
+187 ;; Rate strength according to the following scale:
+188 ;; 0/5 No muscle movement
+189 ;; 1/5 Visible muscle movement, but no joint movement
+190 ;; 2/5 No movement against gravity
+191 ;; 3/5 No movement against resistance
+192 ;; 4/5 Less than normal strength
+193 ;; 5/5 Normal strength
+194 ;;
+195 ;;___ All Normal
+196 ;; Shoulder extension:
+197 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+198 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+199 ;; Shoulder flexion:
+200 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+201 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+202 ;; Elbow flexion:
+203 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+204 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+205 ;; Elbow extension:
+206 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+207 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+208 ;; Wrist flexion:
+209 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+210 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+211 ;; Wrist extension:
+212 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+213 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+214 ;; Grip:
+215 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+216 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+217 ;; Pinch (thumb to index finger):
+218 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+219 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+220 ;; Hip extension:
+221 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+222 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+223 ;; Hip flexion:
+224 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+225 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+226 ;;^TOF^
+227 ;; Knee extension:
+228 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+229 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+230 ;; Ankle plantar flexion:
+231 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+232 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+233 ;; Ankle dorsiflexion:
+234 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+235 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+236 ;;
+237 ;; If there are other weaknesses, please specify using the above format:
+238 ;; ____________________________________________________________________________
+239 ;;
+240 ;; c. Deep tendon reflexes (DTRs)
+241 ;; Rate reflexes according to the following scale:
+242 ;; 0 Absent
+243 ;; 1+ Decreased
+244 ;; 2+ Normal
+245 ;; 3+ Increased without clonus
+246 ;; 4+ Increased with clonus
+247 ;;
+248 ;; ___ All Normal
+249 ;; Biceps: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+250 ;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+251 ;; Triceps: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+252 ;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+253 ;; Brachioradialis:
+254 ;; Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+255 ;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+256 ;; Knee: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+257 ;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+258 ;; Ankle: Right: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+259 ;; Left: ___ 0 ___ 1+ ___ 2+ ___ 3+ ___ 4+
+260 ;;
+261 ;; d. Sensation testing results:
+262 ;;
+263 ;; ___ All Normal
+264 ;; Shoulder area (C5): Right: ___ Normal ___ Decreased ___ Absent
+265 ;; Left: ___ Normal ___ Decreased ___ Absent
+266 ;; Inner/outer forearm (C6/T1):
+267 ;; Right: ___ Normal ___ Decreased ___ Absent
+268 ;; Left: ___ Normal ___ Decreased ___ Absent
+269 ;; Hand/fingers (C6-8): Right: ___ Normal ___ Decreased ___ Absent
+270 ;; Left: ___ Normal ___ Decreased ___ Absent
+271 ;; Thorax:
+272 ;; Anterior: Right: ___ Normal ___ Decreased ___ Absent
+273 ;; Left: ___ Normal ___ Decreased ___ Absent
+274 ;; Posterior: Right: ___ Normal ___ Decreased ___ Absent
+275 ;; Left: ___ Normal ___ Decreased ___ Absent
+276 ;;^TOF^
+277 ;; Trunk:
+278 ;; Anterior: Right: ___ Normal ___ Decreased ___ Absent
+279 ;; Left: ___ Normal ___ Decreased ___ Absent
+280 ;; Posterior: Right: ___ Normal ___ Decreased ___ Absent
+281 ;; Left: ___ Normal ___ Decreased ___ Absent
+282 ;; Thigh/knee (L3/4): Right: ___ Normal ___ Decreased ___ Absent
+283 ;; Left: ___ Normal ___ Decreased ___ Absent
+284 ;; Lower leg/ankle (L4/L5/S1):
+285 ;; Right: ___ Normal ___ Decreased ___ Absent
+286 ;; Left: ___ Normal ___ Decreased ___ Absent
+287 ;; Foot/toes (L5): Right: ___ Normal ___ Decreased ___ Absent
+288 ;; Left: ___ Normal ___ Decreased ___ Absent
+289 ;;
+290 ;; e. Does the Veteran have muscle atrophy attributable to MS?
+291 ;; ___ Yes ___ No
+292 ;; If muscle atrophy is present, indicate location: ___________________________
+293 ;; When possible, provide difference measured in cm between normal and
+294 ;; atrophied side, measured at maximum muscle bulk: _____ cm.
+295 ;;
+296 ;; f. Summary of muscle weakness in the upper and/or lower extremities
+297 ;; attributable to MS (check all that apply):
+298 ;; Right upper extremity muscle weakness:
+299 ;; ___ None___ Mild___ Moderate___ Severe
+300 ;; ___ With atrophy ___ Complete (no remaining function)
+301 ;; Left upper extremity muscle weakness:
+302 ;; ___ None___ Mild___ Moderate___ Severe
+303 ;; ___ With atrophy ___ Complete (no remaining function)
+304 ;; Right lower extremity muscle weakness:
+305 ;; ___ None___ Mild___ Moderate___ Severe
+306 ;; ___ With atrophy ___ Complete (no remaining function)
+307 ;; Left lower extremity muscle weakness:
+308 ;; ___ None___ Mild___ Moderate___ Severe
+309 ;; ___ With atrophy ___ Complete (no remaining function)
+310 ;; NOTE: If the Veteran has more than one medical condition contributing to the
+311 ;; muscle weakness, identify the condition(s) and describe each condition's
+312 ;; contribution to the muscle weakness: _______________________________________
+313 ;;
+314 QUIT
