DVBCQNC2 ;;ALB-CIOFO/ECF - NECK (CERIVCAL SPINE) QUESTIONNAIRE ; 5/15/2011
;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
;
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 now have or has he/she ever been diagnosed with a cervical
;; spine (neck) condition?
;; ___ Yes ___ No
;;
;; NOTE: Provide only diagnoses that pertain to cervical spine (neck)
;; conditions.
;;
;; 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 cervical spine (neck)
;; conditions, list using above format: _______________________________________
;;
;; 2. Medical history
;;
;; Describe the history (including onset and course) of the Veteran's cervical
;; spine (neck) condition (brief summary): ____________________________________
;;
;; 3. Flare-ups
;;
;; Does the Veteran report that flare-ups impact the function of the cervical
;; spine (neck)?
;; ___ Yes ___ No
;;
;; If yes, document the Veteran's description of the impact of flare-ups in his
;; or her own words: __________________________________________________________
;;^TOF^
;; 4. Initial range of motion (ROM) measurements
;;
;; Measure ROM with a goniometer, rounding each measurement to the nearest 5
;; degrees. During the measurements, observe the point at which painful motion
;; begins, evidenced by visible behavior such as facial expression, wincing,
;; etc. Report initial measurements below.
;;
;; Following the initial assessment of ROM, perform repetitive use testing. For
;; VA purposes, repetitive use testing must be included in all exams. The VA
;; has determined that 3 repetitions of ROM can serve as a representative test
;; of the effect of repetitive use. After the initial measurement, reassess ROM
;; after 3 repetitions. Report post-test measurements in section 5.
;;
;; a. Select where forward flexion ends (normal endpoint is 45 degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; Select where objective evidence of painful motion begins:
;; __ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; b. Select where extension ends (normal endpoint is 45 degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; Select where objective evidence of painful motion begins:
;; __ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; c. Select where right lateral flexion ends (normal endpoint is 45
;; degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; Select where objective evidence of painful motion begins:
;; __ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; d. Select where left lateral flexion ends (normal endpoint is 45
;; degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; Select where objective evidence of painful motion begins:
;; __ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;^TOF^
;; e. Select where right lateral rotation ends (normal endpoint is 80
;; degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 or greater
;;
;; f. Select where left lateral rotation ends (normal endpoint is 80
;; degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 or greater
;;
;; g. If ROM does not conform to the normal range of motion identified above
;; but is normal for this Veteran (for reasons other than a cervical spine
;; (neck) condition, such as age, body habitus, neurologic disease), explain:
;; ____________________________________________________________________________
;;
;; 5. ROM measurements after repetitive use testing
;;
;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
;; ___ Yes ___No If unable, provide reason: _____________________________
;;
;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
;; If Veteran is able to perform repetitive-use testing, measure and report ROM
;; after a minimum of 3 repetitions.
;;
;; b. Select where post-test forward flexion ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; c. Select where post-test extension ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; d. Select where post-test right lateral flexion ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;
;; e. Select where post-test left lateral flexion ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
;;^TOF^
;; f. Select where post-test right lateral rotation ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 or greater
;;
;; g. Select where post-test left lateral rotation ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 or greater
;;
;; 6. Functional loss and additional limitation in ROM
;;
;; The following section addresses reasons for functional loss, if present, and
;; additional loss of ROM after repetitive-use testing, if present. The VA
;; defines functional loss as the inability to perform normal working movements
;; of the body with normal excursion, strength, speed, coordination and/or
;; endurance.
;;
;; a. Does the Veteran have additional limitation in ROM of the cervical spine
;; (neck) following repetitive-use testing?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have any functional loss and/or functional impairment of
;; the cervical spine (neck)?
;; ___ Yes ___ No
;;
;; c. If the Veteran has functional loss, functional impairment and/or
;; additional limitation of ROM of the cervical spine (neck) after repetitive
;; use, indicate the contributing factors of disability below:
;; ___ Less movement than normal
;; ___ More movement than normal
;; ___ Weakened movement
;; ___ Excess fatigability
;; ___ Incoordination, impaired ability to execute skilled movements smoothly
;; ___ Pain on movement
;; ___ Swelling
;; ___ Deformity
;; ___ Atrophy of disuse
;; ___ Instability of station
;; ___ Disturbance of locomotion
;; ___ Interference with sitting, standing and/or weight-bearing
;; ___ Other, describe: ____________________________________________________
;;
;; 7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait)
;;
;; a. Does the Veteran have localized tenderness or pain to palpation for
;; joints/soft tissue of the cervical spine (neck)?
;; ___ Yes ___ No
;;^TOF^
;; b. Does the Veteran have guarding or muscle spasm of the cervical spine
;; (neck)?
;; ___ Yes ___ No
;;
;; If yes, is it severe enough to result in: (check all that apply)
;; ___ Abnormal gait
;; ___ Abnormal spinal contour
;; ___ Guarding and/or muscle spasm is present, but do not result in
;; abnormal gait or spinal contour
;;
;; 8. Muscle strength testing
;;
;; a. Rate strength according to the following scale:
;; 0/5 No muscle movement
;; 1/5 Palpable or visible muscle contraction, but no joint movement
;; 2/5 Active movement with gravity eliminated
;; 3/5 Active movement against gravity
;; 4/5 Active movement against some resistance
;; 5/5 Normal strength
;;
;; ___ All normal
;;
;; 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
;; Finger 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
;; Finger Abduction: 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
;;
;; b. Does the Veteran have muscle atrophy?
;; ___ Yes ___ No
;;
;; If muscle atrophy is present, indicate location: ___________________________
;; Provide measurements in centimeters of normal side and atrophied side,
;; measured at maximum muscle bulk:
;; Normal side: _____ cm. Atrophied side: _____ cm.
;;^TOF^
;; 9. Reflex exam
;;
;; Rate deep tendon reflexes (DTRs) according to the following scale:
;; 0 Absent
;; 1+ Hypoactive
;; 2+ Normal
;; 3+ Hyperactive without clonus
;; 4+ Hyperactive 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+
;;
;; 10. Sensory exam
;;
;; Provide results for sensation to light touch (dermatomes) testing:
;;
;; ___ 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
;;
;; Other sensory findings, if any: ____________________________________________
;;
;; 11. Radiculopathy
;;
;; Does the Veteran have radicular pain or any other signs or symptoms due to
;; radiculopathy?
;; ___ Yes ___ No
;; If yes, complete the following section:
;;
;; a. Indicate location and severity of symptoms (check all that apply):
;;
;; Constant pain (may be excruciating at times)
;; Right upper extremity: ___None ___Mild ___Moderate ___Severe
;; Left upper extremity: ___None ___Mild ___Moderate ___Severe
;;
;; Intermittent pain (usually dull)
;; Right upper extremity: ___None ___Mild ___Moderate ___Severe
;; Left upper extremity: ___None ___Mild ___Moderate ___Severe
;;^TOF^
;; Paresthesias and/or dysesthesias
;; Right upper extremity: ___None ___Mild ___Moderate ___Severe
;; Left upper extremity: ___None ___Mild ___Moderate ___Severe
;;
;; Numbness
;; Right upper extremity: ___None ___Mild ___Moderate ___Severe
;; Left upper extremity: ___None ___Mild ___Moderate ___Severe
;;
;; b. Does the Veteran have any other signs or symptoms of radiculopathy?
;; ___ Yes ___ No
;;
;; If yes, describe: __________________________________________________________
;;
;; c. Indicate nerve roots involved: (check all that apply)
;; ___ Involvement of C5/C6 nerve roots (upper radicular group)
;; ___ Involvement of C7 nerve roots (middle radicular group)
;; ___ Involvement of C8/T1 nerve roots (lower radicular group)
;;
;; d. Indicate severity of radiculopathy and side affected:
;; Right: ___ Not affected ___ Mild ___ Moderate ___ Severe
;; Left: ___ Not affected ___ Mild ___ Moderate ___ Severe
;;
;; 12. Other neurologic abnormalities
;;
;; Does the Veteran have any other neurologic abnormalities related to a
;; cervical spine (neck) condition (such as bowel or bladder problems due to
;; cervical myelopathy)?
;; ___ Yes ___ No
;;
;; If yes, describe: __________________________________________________________
;; Also complete appropriate Questionnaire, if indicated.
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQNC2 13811 printed Apr 09, 2024@20:53:36 Page 2
DVBCQNC2 ;;ALB-CIOFO/ECF - NECK (CERIVCAL SPINE) QUESTIONNAIRE ; 5/15/2011
+1 ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs
+3 ;; (VA) for disability benefits. VA will consider the information you
+4 ;; provide on this questionnaire as part of their evaluation in processing
+5 ;; the Veteran's claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran now have or has he/she ever been diagnosed with a cervical
+10 ;; spine (neck) condition?
+11 ;; ___ Yes ___ No
+12 ;;
+13 ;; NOTE: Provide only diagnoses that pertain to cervical spine (neck)
+14 ;; conditions.
+15 ;;
+16 ;; Diagnosis #1: ____________________
+17 ;; ICD code: ________________________
+18 ;; Date of diagnosis: _______________
+19 ;;
+20 ;; Diagnosis #2: ____________________
+21 ;; ICD code: ________________________
+22 ;; Date of diagnosis: _______________
+23 ;;
+24 ;; Diagnosis #3: ____________________
+25 ;; ICD code: ________________________
+26 ;; Date of diagnosis: _______________
+27 ;;
+28 ;; If there are additional diagnoses that pertain to cervical spine (neck)
+29 ;; conditions, list using above format: _______________________________________
+30 ;;
+31 ;; 2. Medical history
+32 ;;
+33 ;; Describe the history (including onset and course) of the Veteran's cervical
+34 ;; spine (neck) condition (brief summary): ____________________________________
+35 ;;
+36 ;; 3. Flare-ups
+37 ;;
+38 ;; Does the Veteran report that flare-ups impact the function of the cervical
+39 ;; spine (neck)?
+40 ;; ___ Yes ___ No
+41 ;;
+42 ;; If yes, document the Veteran's description of the impact of flare-ups in his
+43 ;; or her own words: __________________________________________________________
+44 ;;^TOF^
+45 ;; 4. Initial range of motion (ROM) measurements
+46 ;;
+47 ;; Measure ROM with a goniometer, rounding each measurement to the nearest 5
+48 ;; degrees. During the measurements, observe the point at which painful motion
+49 ;; begins, evidenced by visible behavior such as facial expression, wincing,
+50 ;; etc. Report initial measurements below.
+51 ;;
+52 ;; Following the initial assessment of ROM, perform repetitive use testing. For
+53 ;; VA purposes, repetitive use testing must be included in all exams. The VA
+54 ;; has determined that 3 repetitions of ROM can serve as a representative test
+55 ;; of the effect of repetitive use. After the initial measurement, reassess ROM
+56 ;; after 3 repetitions. Report post-test measurements in section 5.
+57 ;;
+58 ;; a. Select where forward flexion ends (normal endpoint is 45 degrees):
+59 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+60 ;;
+61 ;; Select where objective evidence of painful motion begins:
+62 ;; __ No objective evidence of painful motion
+63 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+64 ;;
+65 ;; b. Select where extension ends (normal endpoint is 45 degrees):
+66 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+67 ;;
+68 ;; Select where objective evidence of painful motion begins:
+69 ;; __ No objective evidence of painful motion
+70 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+71 ;;
+72 ;; c. Select where right lateral flexion ends (normal endpoint is 45
+73 ;; degrees):
+74 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+75 ;;
+76 ;; Select where objective evidence of painful motion begins:
+77 ;; __ No objective evidence of painful motion
+78 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+79 ;;
+80 ;; d. Select where left lateral flexion ends (normal endpoint is 45
+81 ;; degrees):
+82 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+83 ;;
+84 ;; Select where objective evidence of painful motion begins:
+85 ;; __ No objective evidence of painful motion
+86 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+87 ;;^TOF^
+88 ;; e. Select where right lateral rotation ends (normal endpoint is 80
+89 ;; degrees):
+90 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+91 ;; __50 __55 __60 __65 __70 __75 __80 or greater
+92 ;;
+93 ;; Select where objective evidence of painful motion begins:
+94 ;; ___ No objective evidence of painful motion
+95 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+96 ;; __50 __55 __60 __65 __70 __75 __80 or greater
+97 ;;
+98 ;; f. Select where left lateral rotation ends (normal endpoint is 80
+99 ;; degrees):
+100 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+101 ;; __50 __55 __60 __65 __70 __75 __80 or greater
+102 ;;
+103 ;; Select where objective evidence of painful motion begins:
+104 ;; ___ No objective evidence of painful motion
+105 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+106 ;; __50 __55 __60 __65 __70 __75 __80 or greater
+107 ;;
+108 ;; g. If ROM does not conform to the normal range of motion identified above
+109 ;; but is normal for this Veteran (for reasons other than a cervical spine
+110 ;; (neck) condition, such as age, body habitus, neurologic disease), explain:
+111 ;; ____________________________________________________________________________
+112 ;;
+113 ;; 5. ROM measurements after repetitive use testing
+114 ;;
+115 ;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
+116 ;; ___ Yes ___No If unable, provide reason: _____________________________
+117 ;;
+118 ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
+119 ;; If Veteran is able to perform repetitive-use testing, measure and report ROM
+120 ;; after a minimum of 3 repetitions.
+121 ;;
+122 ;; b. Select where post-test forward flexion ends:
+123 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+124 ;;
+125 ;; c. Select where post-test extension ends:
+126 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+127 ;;
+128 ;; d. Select where post-test right lateral flexion ends:
+129 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+130 ;;
+131 ;; e. Select where post-test left lateral flexion ends:
+132 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
+133 ;;^TOF^
+134 ;; f. Select where post-test right lateral rotation ends:
+135 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+136 ;; __50 __55 __60 __65 __70 __75 __80 or greater
+137 ;;
+138 ;; g. Select where post-test left lateral rotation ends:
+139 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+140 ;; __50 __55 __60 __65 __70 __75 __80 or greater
+141 ;;
+142 ;; 6. Functional loss and additional limitation in ROM
+143 ;;
+144 ;; The following section addresses reasons for functional loss, if present, and
+145 ;; additional loss of ROM after repetitive-use testing, if present. The VA
+146 ;; defines functional loss as the inability to perform normal working movements
+147 ;; of the body with normal excursion, strength, speed, coordination and/or
+148 ;; endurance.
+149 ;;
+150 ;; a. Does the Veteran have additional limitation in ROM of the cervical spine
+151 ;; (neck) following repetitive-use testing?
+152 ;; ___ Yes ___ No
+153 ;;
+154 ;; b. Does the Veteran have any functional loss and/or functional impairment of
+155 ;; the cervical spine (neck)?
+156 ;; ___ Yes ___ No
+157 ;;
+158 ;; c. If the Veteran has functional loss, functional impairment and/or
+159 ;; additional limitation of ROM of the cervical spine (neck) after repetitive
+160 ;; use, indicate the contributing factors of disability below:
+161 ;; ___ Less movement than normal
+162 ;; ___ More movement than normal
+163 ;; ___ Weakened movement
+164 ;; ___ Excess fatigability
+165 ;; ___ Incoordination, impaired ability to execute skilled movements smoothly
+166 ;; ___ Pain on movement
+167 ;; ___ Swelling
+168 ;; ___ Deformity
+169 ;; ___ Atrophy of disuse
+170 ;; ___ Instability of station
+171 ;; ___ Disturbance of locomotion
+172 ;; ___ Interference with sitting, standing and/or weight-bearing
+173 ;; ___ Other, describe: ____________________________________________________
+174 ;;
+175 ;; 7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait)
+176 ;;
+177 ;; a. Does the Veteran have localized tenderness or pain to palpation for
+178 ;; joints/soft tissue of the cervical spine (neck)?
+179 ;; ___ Yes ___ No
+180 ;;^TOF^
+181 ;; b. Does the Veteran have guarding or muscle spasm of the cervical spine
+182 ;; (neck)?
+183 ;; ___ Yes ___ No
+184 ;;
+185 ;; If yes, is it severe enough to result in: (check all that apply)
+186 ;; ___ Abnormal gait
+187 ;; ___ Abnormal spinal contour
+188 ;; ___ Guarding and/or muscle spasm is present, but do not result in
+189 ;; abnormal gait or spinal contour
+190 ;;
+191 ;; 8. Muscle strength testing
+192 ;;
+193 ;; a. Rate strength according to the following scale:
+194 ;; 0/5 No muscle movement
+195 ;; 1/5 Palpable or visible muscle contraction, but no joint movement
+196 ;; 2/5 Active movement with gravity eliminated
+197 ;; 3/5 Active movement against gravity
+198 ;; 4/5 Active movement against some resistance
+199 ;; 5/5 Normal strength
+200 ;;
+201 ;; ___ All normal
+202 ;;
+203 ;; Elbow flexion: 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 Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+206 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+207 ;; Wrist flexion: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+208 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+209 ;; Wrist extension: 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 ;; Finger Flexion: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+212 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+213 ;; Finger Abduction: Right: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+214 ;; Left: __5/5 __4/5 __3/5 __2/5 __1/5 __0/5
+215 ;;
+216 ;; b. Does the Veteran have muscle atrophy?
+217 ;; ___ Yes ___ No
+218 ;;
+219 ;; If muscle atrophy is present, indicate location: ___________________________
+220 ;; Provide measurements in centimeters of normal side and atrophied side,
+221 ;; measured at maximum muscle bulk:
+222 ;; Normal side: _____ cm. Atrophied side: _____ cm.
+223 ;;^TOF^
+224 ;; 9. Reflex exam
+225 ;;
+226 ;; Rate deep tendon reflexes (DTRs) according to the following scale:
+227 ;; 0 Absent
+228 ;; 1+ Hypoactive
+229 ;; 2+ Normal
+230 ;; 3+ Hyperactive without clonus
+231 ;; 4+ Hyperactive with clonus
+232 ;;
+233 ;; ___ All normal
+234 ;;
+235 ;; Biceps: Right: __0 __1+ __2+ __3+ __4+
+236 ;; Left: __0 __1+ __2+ __3+ __4+
+237 ;; Triceps: Right: __0 __1+ __2+ __3+ __4+
+238 ;; Left: __0 __1+ __2+ __3+ __4+
+239 ;; Brachioradialis: Right: __0 __1+ __2+ __3+ __4+
+240 ;; Left: __0 __1+ __2+ __3+ __4+
+241 ;;
+242 ;; 10. Sensory exam
+243 ;;
+244 ;; Provide results for sensation to light touch (dermatomes) testing:
+245 ;;
+246 ;; ___ All normal
+247 ;; Shoulder area (C5): Right: __Normal __Decreased __Absent
+248 ;; Left: __Normal __Decreased __Absent
+249 ;; Inner/outer forearm (C6/T1): Right: __Normal __Decreased __Absent
+250 ;; Left: __Normal __Decreased __Absent
+251 ;; Hand/fingers (C6-8): Right: __Normal __Decreased __Absent
+252 ;; Left: __Normal __Decreased __Absent
+253 ;;
+254 ;; Other sensory findings, if any: ____________________________________________
+255 ;;
+256 ;; 11. Radiculopathy
+257 ;;
+258 ;; Does the Veteran have radicular pain or any other signs or symptoms due to
+259 ;; radiculopathy?
+260 ;; ___ Yes ___ No
+261 ;; If yes, complete the following section:
+262 ;;
+263 ;; a. Indicate location and severity of symptoms (check all that apply):
+264 ;;
+265 ;; Constant pain (may be excruciating at times)
+266 ;; Right upper extremity: ___None ___Mild ___Moderate ___Severe
+267 ;; Left upper extremity: ___None ___Mild ___Moderate ___Severe
+268 ;;
+269 ;; Intermittent pain (usually dull)
+270 ;; Right upper extremity: ___None ___Mild ___Moderate ___Severe
+271 ;; Left upper extremity: ___None ___Mild ___Moderate ___Severe
+272 ;;^TOF^
+273 ;; Paresthesias and/or dysesthesias
+274 ;; Right upper extremity: ___None ___Mild ___Moderate ___Severe
+275 ;; Left upper extremity: ___None ___Mild ___Moderate ___Severe
+276 ;;
+277 ;; Numbness
+278 ;; Right upper extremity: ___None ___Mild ___Moderate ___Severe
+279 ;; Left upper extremity: ___None ___Mild ___Moderate ___Severe
+280 ;;
+281 ;; b. Does the Veteran have any other signs or symptoms of radiculopathy?
+282 ;; ___ Yes ___ No
+283 ;;
+284 ;; If yes, describe: __________________________________________________________
+285 ;;
+286 ;; c. Indicate nerve roots involved: (check all that apply)
+287 ;; ___ Involvement of C5/C6 nerve roots (upper radicular group)
+288 ;; ___ Involvement of C7 nerve roots (middle radicular group)
+289 ;; ___ Involvement of C8/T1 nerve roots (lower radicular group)
+290 ;;
+291 ;; d. Indicate severity of radiculopathy and side affected:
+292 ;; Right: ___ Not affected ___ Mild ___ Moderate ___ Severe
+293 ;; Left: ___ Not affected ___ Mild ___ Moderate ___ Severe
+294 ;;
+295 ;; 12. Other neurologic abnormalities
+296 ;;
+297 ;; Does the Veteran have any other neurologic abnormalities related to a
+298 ;; cervical spine (neck) condition (such as bowel or bladder problems due to
+299 ;; cervical myelopathy)?
+300 ;; ___ Yes ___ No
+301 ;;
+302 ;; If yes, describe: __________________________________________________________
+303 ;; Also complete appropriate Questionnaire, if indicated.
+304 QUIT
