- 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 Feb 18, 2025@23:13:52 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