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Routine: DVBCQNC2

DVBCQNC2.m

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  1. DVBCQNC2 ;;ALB-CIOFO/ECF - NECK (CERIVCAL SPINE) QUESTIONNAIRE ; 5/15/2011
  1. ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
  1. ;
  1. TXT ;
  1. ;;
  1. ;; Your patient is applying to the U. S. Department of Veterans Affairs
  1. ;; (VA) for disability benefits. VA will consider the information you
  1. ;; provide on this questionnaire as part of their evaluation in processing
  1. ;; the Veteran's claim.
  1. ;;
  1. ;; 1. Diagnosis
  1. ;;
  1. ;; Does the Veteran now have or has he/she ever been diagnosed with a cervical
  1. ;; spine (neck) condition?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; NOTE: Provide only diagnoses that pertain to cervical spine (neck)
  1. ;; conditions.
  1. ;;
  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 cervical spine (neck)
  1. ;; conditions, list using above format: _______________________________________
  1. ;;
  1. ;; 2. Medical history
  1. ;;
  1. ;; Describe the history (including onset and course) of the Veteran's cervical
  1. ;; spine (neck) condition (brief summary): ____________________________________
  1. ;;
  1. ;; 3. Flare-ups
  1. ;;
  1. ;; Does the Veteran report that flare-ups impact the function of the cervical
  1. ;; spine (neck)?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, document the Veteran's description of the impact of flare-ups in his
  1. ;; or her own words: __________________________________________________________
  1. ;;^TOF^
  1. ;; 4. Initial range of motion (ROM) measurements
  1. ;;
  1. ;; Measure ROM with a goniometer, rounding each measurement to the nearest 5
  1. ;; degrees. During the measurements, observe the point at which painful motion
  1. ;; begins, evidenced by visible behavior such as facial expression, wincing,
  1. ;; etc. Report initial measurements below.
  1. ;;
  1. ;; Following the initial assessment of ROM, perform repetitive use testing. For
  1. ;; VA purposes, repetitive use testing must be included in all exams. The VA
  1. ;; has determined that 3 repetitions of ROM can serve as a representative test
  1. ;; of the effect of repetitive use. After the initial measurement, reassess ROM
  1. ;; after 3 repetitions. Report post-test measurements in section 5.
  1. ;;
  1. ;; a. Select where forward flexion ends (normal endpoint is 45 degrees):
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
  1. ;;
  1. ;; Select where objective evidence of painful motion begins:
  1. ;; __ No objective evidence of painful motion
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
  1. ;;
  1. ;; b. Select where extension ends (normal endpoint is 45 degrees):
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
  1. ;;
  1. ;; Select where objective evidence of painful motion begins:
  1. ;; __ No objective evidence of painful motion
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
  1. ;;
  1. ;; c. Select where right lateral flexion ends (normal endpoint is 45
  1. ;; degrees):
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
  1. ;;
  1. ;; Select where objective evidence of painful motion begins:
  1. ;; __ No objective evidence of painful motion
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
  1. ;;
  1. ;; d. Select where left lateral flexion ends (normal endpoint is 45
  1. ;; degrees):
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
  1. ;;
  1. ;; Select where objective evidence of painful motion begins:
  1. ;; __ No objective evidence of painful motion
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
  1. ;;^TOF^
  1. ;; e. Select where right lateral rotation ends (normal endpoint is 80
  1. ;; degrees):
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
  1. ;; __50 __55 __60 __65 __70 __75 __80 or greater
  1. ;;
  1. ;; Select where objective evidence of painful motion begins:
  1. ;; ___ No objective evidence of painful motion
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
  1. ;; __50 __55 __60 __65 __70 __75 __80 or greater
  1. ;;
  1. ;; f. Select where left lateral rotation ends (normal endpoint is 80
  1. ;; degrees):
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
  1. ;; __50 __55 __60 __65 __70 __75 __80 or greater
  1. ;;
  1. ;; Select where objective evidence of painful motion begins:
  1. ;; ___ No objective evidence of painful motion
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
  1. ;; __50 __55 __60 __65 __70 __75 __80 or greater
  1. ;;
  1. ;; g. If ROM does not conform to the normal range of motion identified above
  1. ;; but is normal for this Veteran (for reasons other than a cervical spine
  1. ;; (neck) condition, such as age, body habitus, neurologic disease), explain:
  1. ;; ____________________________________________________________________________
  1. ;;
  1. ;; 5. ROM measurements after repetitive use testing
  1. ;;
  1. ;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
  1. ;; ___ Yes ___No If unable, provide reason: _____________________________
  1. ;;
  1. ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
  1. ;; If Veteran is able to perform repetitive-use testing, measure and report ROM
  1. ;; after a minimum of 3 repetitions.
  1. ;;
  1. ;; b. Select where post-test forward flexion ends:
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
  1. ;;
  1. ;; c. Select where post-test extension ends:
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
  1. ;;
  1. ;; d. Select where post-test right lateral flexion ends:
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
  1. ;;
  1. ;; e. Select where post-test left lateral flexion ends:
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45 or greater
  1. ;;^TOF^
  1. ;; f. Select where post-test right lateral rotation ends:
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
  1. ;; __50 __55 __60 __65 __70 __75 __80 or greater
  1. ;;
  1. ;; g. Select where post-test left lateral rotation ends:
  1. ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
  1. ;; __50 __55 __60 __65 __70 __75 __80 or greater
  1. ;;
  1. ;; 6. Functional loss and additional limitation in ROM
  1. ;;
  1. ;; The following section addresses reasons for functional loss, if present, and
  1. ;; additional loss of ROM after repetitive-use testing, if present. The VA
  1. ;; defines functional loss as the inability to perform normal working movements
  1. ;; of the body with normal excursion, strength, speed, coordination and/or
  1. ;; endurance.
  1. ;;
  1. ;; a. Does the Veteran have additional limitation in ROM of the cervical spine
  1. ;; (neck) following repetitive-use testing?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; b. Does the Veteran have any functional loss and/or functional impairment of
  1. ;; the cervical spine (neck)?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; c. If the Veteran has functional loss, functional impairment and/or
  1. ;; additional limitation of ROM of the cervical spine (neck) after repetitive
  1. ;; use, indicate the contributing factors of disability below:
  1. ;; ___ Less movement than normal
  1. ;; ___ More movement than normal
  1. ;; ___ Weakened movement
  1. ;; ___ Excess fatigability
  1. ;; ___ Incoordination, impaired ability to execute skilled movements smoothly
  1. ;; ___ Pain on movement
  1. ;; ___ Swelling
  1. ;; ___ Deformity
  1. ;; ___ Atrophy of disuse
  1. ;; ___ Instability of station
  1. ;; ___ Disturbance of locomotion
  1. ;; ___ Interference with sitting, standing and/or weight-bearing
  1. ;; ___ Other, describe: ____________________________________________________
  1. ;;
  1. ;; 7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait)
  1. ;;
  1. ;; a. Does the Veteran have localized tenderness or pain to palpation for
  1. ;; joints/soft tissue of the cervical spine (neck)?
  1. ;; ___ Yes ___ No
  1. ;;^TOF^
  1. ;; b. Does the Veteran have guarding or muscle spasm of the cervical spine
  1. ;; (neck)?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, is it severe enough to result in: (check all that apply)
  1. ;; ___ Abnormal gait
  1. ;; ___ Abnormal spinal contour
  1. ;; ___ Guarding and/or muscle spasm is present, but do not result in
  1. ;; abnormal gait or spinal contour
  1. ;;
  1. ;; 8. Muscle strength testing
  1. ;;
  1. ;; a. Rate strength according to the following scale:
  1. ;; 0/5 No muscle movement
  1. ;; 1/5 Palpable or visible muscle contraction, but no joint movement
  1. ;; 2/5 Active movement with gravity eliminated
  1. ;; 3/5 Active movement against gravity
  1. ;; 4/5 Active movement against some resistance
  1. ;; 5/5 Normal strength
  1. ;;
  1. ;; ___ All normal
  1. ;;
  1. ;; Elbow flexion: 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 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: 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: 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. ;; Finger Flexion: 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. ;; Finger Abduction: 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. ;; b. Does the Veteran have muscle atrophy?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If muscle atrophy is present, indicate location: ___________________________
  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. ;;^TOF^
  1. ;; 9. Reflex exam
  1. ;;
  1. ;; Rate deep tendon reflexes (DTRs) according to the following scale:
  1. ;; 0 Absent
  1. ;; 1+ Hypoactive
  1. ;; 2+ Normal
  1. ;; 3+ Hyperactive without clonus
  1. ;; 4+ Hyperactive with clonus
  1. ;;
  1. ;; ___ All normal
  1. ;;
  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: Right: __0 __1+ __2+ __3+ __4+
  1. ;; Left: __0 __1+ __2+ __3+ __4+
  1. ;;
  1. ;; 10. Sensory exam
  1. ;;
  1. ;; Provide results for sensation to light touch (dermatomes) testing:
  1. ;;
  1. ;; ___ All normal
  1. ;; Shoulder area (C5): Right: __Normal __Decreased __Absent
  1. ;; Left: __Normal __Decreased __Absent
  1. ;; Inner/outer forearm (C6/T1): Right: __Normal __Decreased __Absent
  1. ;; Left: __Normal __Decreased __Absent
  1. ;; Hand/fingers (C6-8): Right: __Normal __Decreased __Absent
  1. ;; Left: __Normal __Decreased __Absent
  1. ;;
  1. ;; Other sensory findings, if any: ____________________________________________
  1. ;;
  1. ;; 11. Radiculopathy
  1. ;;
  1. ;; Does the Veteran have radicular pain or any other signs or symptoms due to
  1. ;; radiculopathy?
  1. ;; ___ Yes ___ No
  1. ;; If yes, complete the following section:
  1. ;;
  1. ;; a. Indicate location and severity of symptoms (check all that apply):
  1. ;;
  1. ;; Constant pain (may be excruciating at times)
  1. ;; Right upper extremity: ___None ___Mild ___Moderate ___Severe
  1. ;; Left upper extremity: ___None ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; Intermittent pain (usually dull)
  1. ;; Right upper extremity: ___None ___Mild ___Moderate ___Severe
  1. ;; Left upper extremity: ___None ___Mild ___Moderate ___Severe
  1. ;;^TOF^
  1. ;; Paresthesias and/or dysesthesias
  1. ;; Right upper extremity: ___None ___Mild ___Moderate ___Severe
  1. ;; Left upper extremity: ___None ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; Numbness
  1. ;; Right upper extremity: ___None ___Mild ___Moderate ___Severe
  1. ;; Left upper extremity: ___None ___Mild ___Moderate ___Severe
  1. ;;
  1. ;; b. Does the Veteran have any other signs or symptoms of radiculopathy?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, describe: __________________________________________________________
  1. ;;
  1. ;; c. Indicate nerve roots involved: (check all that apply)
  1. ;; ___ Involvement of C5/C6 nerve roots (upper radicular group)
  1. ;; ___ Involvement of C7 nerve roots (middle radicular group)
  1. ;; ___ Involvement of C8/T1 nerve roots (lower radicular group)
  1. ;;
  1. ;; d. Indicate severity of radiculopathy and side affected:
  1. ;; Right: ___ Not affected ___ Mild ___ Moderate ___ Severe
  1. ;; Left: ___ Not affected ___ Mild ___ Moderate ___ Severe
  1. ;;
  1. ;; 12. Other neurologic abnormalities
  1. ;;
  1. ;; Does the Veteran have any other neurologic abnormalities related to a
  1. ;; cervical spine (neck) condition (such as bowel or bladder problems due to
  1. ;; cervical myelopathy)?
  1. ;; ___ Yes ___ No
  1. ;;
  1. ;; If yes, describe: __________________________________________________________
  1. ;; Also complete appropriate Questionnaire, if indicated.
  1. Q