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Routine: DVBCQNC3

DVBCQNC3.m

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  1. DVBCQNC3 ;;ALB-CIOFO/ECF -  NECK (CERIVCAL SPINE) QUESTIONNAIRE CONT'D; 5/15/2011
  1.  ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;;^TOF^
  1.  ;; 13. Intervertebral disc syndrome (IVDS) and incapacitating episodes
  1.  ;;
  1.  ;; a. Does the Veteran have IVDS of the cervical spine?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; b. If yes, has the Veteran had any incapacitating episodes over the past 12
  1.  ;; months due to IVDS?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; NOTE: For VA purposes, an incapacitating episode is a period of acute
  1.  ;; symptoms severe enough to require prescribed bed rest and treatment by a
  1.  ;; physician.
  1.  ;;
  1.  ;;    If yes, provide the total duration over the past 12 months:
  1.  ;;    ___ Less than 1 week
  1.  ;;    ___ At least 1 week but less than 2 weeks
  1.  ;;    ___ At least 2 weeks but less than 4 weeks
  1.  ;;    ___ At least 4 weeks but less than 6 weeks
  1.  ;;    ___ At least 6 weeks
  1.  ;;
  1.  ;; 14. Assistive devices
  1.  ;;
  1.  ;; a. Does the Veteran use any assistive device(s) as a normal mode of
  1.  ;; locomotion, although occasional locomotion by other methods may be possible?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, identify assistive device(s) used (check all that apply and indicate
  1.  ;; frequency):
  1.  ;;   __ Wheelchair   Frequency of use:   __Occasional    __Regular   __Constant
  1.  ;;   __ Brace(s)     Frequency of use:   __Occasional    __Regular   __Constant
  1.  ;;   __ Crutch(es)   Frequency of use:   __Occasional    __Regular   __Constant
  1.  ;;   __ Cane(s)      Frequency of use:   __Occasional    __Regular   __Constant
  1.  ;;   __ Walker       Frequency of use:   __Occasional    __Regular   __Constant
  1.  ;;   __ Other: ________________________________________________________________
  1.  ;;                   Frequency of use:   __Occasional    __Regular   __Constant
  1.  ;;
  1.  ;; b. If the Veteran uses any assistive devices, specify the condition and
  1.  ;; identify the assistive device used for each condition: _____________________
  1.  ;; ____________________________________________________________________________
  1.  ;;^TOF^
  1.  ;; 15. Remaining effective function of the extremities
  1.  ;;
  1.  ;; Due to a cervical spine (neck) condition, is there functional impairment
  1.  ;; of an extremity such that no effective function remains other than that
  1.  ;; which would be equally well served by an amputation with prosthesis?
  1.  ;; (Functions of the upper extremity include grasping, manipulation, etc.;
  1.  ;; functions of the lower extremity include balance and propulsion, etc.)
  1.  ;;
  1.  ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
  1.  ;; equally serve the Veteran.
  1.  ;; ___ No
  1.  ;;     If yes, indicate extremity(ies) (check all extremities for which this
  1.  ;;     applies):
  1.  ;;         ___ Right upper   ___ Left upper
  1.  ;;
  1.  ;; 16. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  1.  ;;
  1.  ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
  1.  ;; conditions or to the treatment of any conditions listed in the Diagnosis
  1.  ;; section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, are any of the scars painful and/or unstable, or is the total area
  1.  ;; of all related scars greater than 39 square cm (6 square inches)?
  1.  ;;     ___ Yes   ___ No
  1.  ;;         If yes, also complete a Scars Questionnaire.
  1.  ;;
  1.  ;; b. Does the Veteran have any other pertinent physical findings,
  1.  ;; complications, conditions, signs or symptoms?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe (brief summary): __________________________________________
  1.  ;;^TOF^
  1.  ;; 17. Diagnostic testing
  1.  ;;
  1.  ;; The diagnosis of arthritis must be confirmed by imaging studies. Once
  1.  ;; arthritis has been documented, no further imaging studies are required
  1.  ;; by VA, even if arthritis has worsened.
  1.  ;;
  1.  ;; Imaging studies are not required to make the diagnosis of IVDS;
  1.  ;; Electromyography (EMG) studies are rarely required to diagnose radiculopathy
  1.  ;; in the appropriate clinical setting.
  1.  ;;
  1.  ;; For purposes of this examination, the diagnosis of IVDS and/or radiculopathy
  1.  ;; can be made by a history of characteristic radiating pain and/or sensory
  1.  ;; changes in the arms, and objective clinical findings, which may include the
  1.  ;; asymmetrical loss or decrease of reflexes, decreased strength and/or
  1.  ;; abnormal sensation.
  1.  ;;
  1.  ;; a. Have imaging studies of the cervical spine been performed and are the
  1.  ;; results available?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, is arthritis (degenerative joint disease) documented?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; b. Does the Veteran have a vertebral fracture?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide percent of loss of vertebral body: ____________
  1.  ;;
  1.  ;; c. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;; ____________________________________________________________________________
  1.  ;;
  1.  ;;^TOF^
  1.  ;; 18. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's cervical spine (neck) condition impact his or her
  1.  ;; ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe the impact of each of the Veteran's cervical spine (neck)
  1.  ;; conditions, providing one or more examples _________________________________
  1.  ;;
  1.  ;;_____________________________________________________________________________
  1.  ;;
  1.  ;; 19. Remarks, if any: _______________________________________________________
  1.  ;;
  1.  ;; Physician signature: ____________________________________ Date: ____________
  1.  ;;
  1.  ;; Physician printed name: ____________________________________________________
  1.  ;;
  1.  ;; Medical license #: _________________________________________________________
  1.  ;;
  1.  ;; Physician address: _________________________________________________________
  1.  ;;
  1.  ;; Phone: _____________________________     FAX: ______________________________
  1.  ;;
  1.  ;; NOTE: VA may request additional medical information, including additional
  1.  ;; examinations if necessary to complete VA's review of the Veteran's
  1.  ;; application.
  1.  ;; 
  1.  ;;^END^
  1.  Q