DVBCQNC3 ;;ALB-CIOFO/ECF - NECK (CERIVCAL SPINE) QUESTIONNAIRE CONT'D; 5/15/2011
;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
;
TXT ;
;;
;;^TOF^
;; 13. Intervertebral disc syndrome (IVDS) and incapacitating episodes
;;
;; a. Does the Veteran have IVDS of the cervical spine?
;; ___ Yes ___ No
;;
;; b. If yes, has the Veteran had any incapacitating episodes over the past 12
;; months due to IVDS?
;; ___ Yes ___ No
;;
;; NOTE: For VA purposes, an incapacitating episode is a period of acute
;; symptoms severe enough to require prescribed bed rest and treatment by a
;; physician.
;;
;; If yes, provide the total duration over the past 12 months:
;; ___ Less than 1 week
;; ___ At least 1 week but less than 2 weeks
;; ___ At least 2 weeks but less than 4 weeks
;; ___ At least 4 weeks but less than 6 weeks
;; ___ At least 6 weeks
;;
;; 14. Assistive devices
;;
;; a. Does the Veteran use any assistive device(s) as a normal mode of
;; locomotion, although occasional locomotion by other methods may be possible?
;; ___ Yes ___ No
;;
;; If yes, identify assistive device(s) used (check all that apply and indicate
;; frequency):
;; __ Wheelchair Frequency of use: __Occasional __Regular __Constant
;; __ Brace(s) Frequency of use: __Occasional __Regular __Constant
;; __ Crutch(es) Frequency of use: __Occasional __Regular __Constant
;; __ Cane(s) Frequency of use: __Occasional __Regular __Constant
;; __ Walker Frequency of use: __Occasional __Regular __Constant
;; __ Other: ________________________________________________________________
;; Frequency of use: __Occasional __Regular __Constant
;;
;; b. If the Veteran uses any assistive devices, specify the condition and
;; identify the assistive device used for each condition: _____________________
;; ____________________________________________________________________________
;;^TOF^
;; 15. Remaining effective function of the extremities
;;
;; Due to a cervical spine (neck) condition, is there functional impairment
;; of an extremity such that no effective function remains other than that
;; which would be equally well served by an amputation with prosthesis?
;; (Functions of the upper extremity include grasping, manipulation, etc.;
;; functions of the lower extremity include balance and propulsion, etc.)
;;
;; ___ Yes, functioning is so diminished that amputation with prosthesis would
;; equally serve the Veteran.
;; ___ No
;; If yes, indicate extremity(ies) (check all extremities for which this
;; applies):
;; ___ Right upper ___ Left upper
;;
;; 16. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;;
;; a. Does the Veteran have any scars (surgical or otherwise) related to any
;; conditions or to the treatment of any conditions listed in the Diagnosis
;; section above?
;; ___ Yes ___ No
;; If yes, are any of the scars painful and/or unstable, or is the total area
;; of all related scars greater than 39 square cm (6 square inches)?
;; ___ Yes ___ No
;; If yes, also complete a Scars Questionnaire.
;;
;; b. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs or symptoms?
;; ___ Yes ___ No
;;
;; If yes, describe (brief summary): __________________________________________
;;^TOF^
;; 17. Diagnostic testing
;;
;; The diagnosis of arthritis must be confirmed by imaging studies. Once
;; arthritis has been documented, no further imaging studies are required
;; by VA, even if arthritis has worsened.
;;
;; Imaging studies are not required to make the diagnosis of IVDS;
;; Electromyography (EMG) studies are rarely required to diagnose radiculopathy
;; in the appropriate clinical setting.
;;
;; For purposes of this examination, the diagnosis of IVDS and/or radiculopathy
;; can be made by a history of characteristic radiating pain and/or sensory
;; changes in the arms, and objective clinical findings, which may include the
;; asymmetrical loss or decrease of reflexes, decreased strength and/or
;; abnormal sensation.
;;
;; a. Have imaging studies of the cervical spine been performed and are the
;; results available?
;; ___ Yes ___ No
;;
;; If yes, is arthritis (degenerative joint disease) documented?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have a vertebral fracture?
;; ___ Yes ___ No
;;
;; If yes, provide percent of loss of vertebral body: ____________
;;
;; c. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;;
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;
;; ____________________________________________________________________________
;;
;;^TOF^
;; 18. Functional impact
;;
;; Does the Veteran's cervical spine (neck) condition impact his or her
;; ability to work?
;; ___ Yes ___ No
;;
;; If yes, describe the impact of each of the Veteran's cervical spine (neck)
;; conditions, providing one or more examples _________________________________
;;
;;_____________________________________________________________________________
;;
;; 19. Remarks, if any: _______________________________________________________
;;
;; Physician signature: ____________________________________ Date: ____________
;;
;; Physician printed name: ____________________________________________________
;;
;; Medical license #: _________________________________________________________
;;
;; Physician address: _________________________________________________________
;;
;; Phone: _____________________________ FAX: ______________________________
;;
;; NOTE: VA may request additional medical information, including additional
;; examinations if necessary to complete VA's review of the Veteran's
;; application.
;;
;;^END^
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQNC3 6197 printed Nov 22, 2024@16:57:39 Page 2
DVBCQNC3 ;;ALB-CIOFO/ECF - NECK (CERIVCAL SPINE) QUESTIONNAIRE CONT'D; 5/15/2011
+1 ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
+2 ;
TXT ;
+1 ;;
+2 ;;^TOF^
+3 ;; 13. Intervertebral disc syndrome (IVDS) and incapacitating episodes
+4 ;;
+5 ;; a. Does the Veteran have IVDS of the cervical spine?
+6 ;; ___ Yes ___ No
+7 ;;
+8 ;; b. If yes, has the Veteran had any incapacitating episodes over the past 12
+9 ;; months due to IVDS?
+10 ;; ___ Yes ___ No
+11 ;;
+12 ;; NOTE: For VA purposes, an incapacitating episode is a period of acute
+13 ;; symptoms severe enough to require prescribed bed rest and treatment by a
+14 ;; physician.
+15 ;;
+16 ;; If yes, provide the total duration over the past 12 months:
+17 ;; ___ Less than 1 week
+18 ;; ___ At least 1 week but less than 2 weeks
+19 ;; ___ At least 2 weeks but less than 4 weeks
+20 ;; ___ At least 4 weeks but less than 6 weeks
+21 ;; ___ At least 6 weeks
+22 ;;
+23 ;; 14. Assistive devices
+24 ;;
+25 ;; a. Does the Veteran use any assistive device(s) as a normal mode of
+26 ;; locomotion, although occasional locomotion by other methods may be possible?
+27 ;; ___ Yes ___ No
+28 ;;
+29 ;; If yes, identify assistive device(s) used (check all that apply and indicate
+30 ;; frequency):
+31 ;; __ Wheelchair Frequency of use: __Occasional __Regular __Constant
+32 ;; __ Brace(s) Frequency of use: __Occasional __Regular __Constant
+33 ;; __ Crutch(es) Frequency of use: __Occasional __Regular __Constant
+34 ;; __ Cane(s) Frequency of use: __Occasional __Regular __Constant
+35 ;; __ Walker Frequency of use: __Occasional __Regular __Constant
+36 ;; __ Other: ________________________________________________________________
+37 ;; Frequency of use: __Occasional __Regular __Constant
+38 ;;
+39 ;; b. If the Veteran uses any assistive devices, specify the condition and
+40 ;; identify the assistive device used for each condition: _____________________
+41 ;; ____________________________________________________________________________
+42 ;;^TOF^
+43 ;; 15. Remaining effective function of the extremities
+44 ;;
+45 ;; Due to a cervical spine (neck) condition, is there functional impairment
+46 ;; of an extremity such that no effective function remains other than that
+47 ;; which would be equally well served by an amputation with prosthesis?
+48 ;; (Functions of the upper extremity include grasping, manipulation, etc.;
+49 ;; functions of the lower extremity include balance and propulsion, etc.)
+50 ;;
+51 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+52 ;; equally serve the Veteran.
+53 ;; ___ No
+54 ;; If yes, indicate extremity(ies) (check all extremities for which this
+55 ;; applies):
+56 ;; ___ Right upper ___ Left upper
+57 ;;
+58 ;; 16. Other pertinent physical findings, complications, conditions, signs
+59 ;; and/or symptoms
+60 ;;
+61 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+62 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+63 ;; section above?
+64 ;; ___ Yes ___ No
+65 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+66 ;; of all related scars greater than 39 square cm (6 square inches)?
+67 ;; ___ Yes ___ No
+68 ;; If yes, also complete a Scars Questionnaire.
+69 ;;
+70 ;; b. Does the Veteran have any other pertinent physical findings,
+71 ;; complications, conditions, signs or symptoms?
+72 ;; ___ Yes ___ No
+73 ;;
+74 ;; If yes, describe (brief summary): __________________________________________
+75 ;;^TOF^
+76 ;; 17. Diagnostic testing
+77 ;;
+78 ;; The diagnosis of arthritis must be confirmed by imaging studies. Once
+79 ;; arthritis has been documented, no further imaging studies are required
+80 ;; by VA, even if arthritis has worsened.
+81 ;;
+82 ;; Imaging studies are not required to make the diagnosis of IVDS;
+83 ;; Electromyography (EMG) studies are rarely required to diagnose radiculopathy
+84 ;; in the appropriate clinical setting.
+85 ;;
+86 ;; For purposes of this examination, the diagnosis of IVDS and/or radiculopathy
+87 ;; can be made by a history of characteristic radiating pain and/or sensory
+88 ;; changes in the arms, and objective clinical findings, which may include the
+89 ;; asymmetrical loss or decrease of reflexes, decreased strength and/or
+90 ;; abnormal sensation.
+91 ;;
+92 ;; a. Have imaging studies of the cervical spine been performed and are the
+93 ;; results available?
+94 ;; ___ Yes ___ No
+95 ;;
+96 ;; If yes, is arthritis (degenerative joint disease) documented?
+97 ;; ___ Yes ___ No
+98 ;;
+99 ;; b. Does the Veteran have a vertebral fracture?
+100 ;; ___ Yes ___ No
+101 ;;
+102 ;; If yes, provide percent of loss of vertebral body: ____________
+103 ;;
+104 ;; c. Are there any other significant diagnostic test findings and/or results?
+105 ;; ___ Yes ___ No
+106 ;;
+107 ;; If yes, provide type of test or procedure, date and results (brief summary):
+108 ;; ____________________________________________________________________________
+109 ;;
+110 ;; ____________________________________________________________________________
+111 ;;
+112 ;;^TOF^
+113 ;; 18. Functional impact
+114 ;;
+115 ;; Does the Veteran's cervical spine (neck) condition impact his or her
+116 ;; ability to work?
+117 ;; ___ Yes ___ No
+118 ;;
+119 ;; If yes, describe the impact of each of the Veteran's cervical spine (neck)
+120 ;; conditions, providing one or more examples _________________________________
+121 ;;
+122 ;;_____________________________________________________________________________
+123 ;;
+124 ;; 19. Remarks, if any: _______________________________________________________
+125 ;;
+126 ;; Physician signature: ____________________________________ Date: ____________
+127 ;;
+128 ;; Physician printed name: ____________________________________________________
+129 ;;
+130 ;; Medical license #: _________________________________________________________
+131 ;;
+132 ;; Physician address: _________________________________________________________
+133 ;;
+134 ;; Phone: _____________________________ FAX: ______________________________
+135 ;;
+136 ;; NOTE: VA may request additional medical information, including additional
+137 ;; examinations if necessary to complete VA's review of the Veteran's
+138 ;; application.
+139 ;;
+140 ;;^END^
+141 QUIT
