DVBCQPN2.m

DVBCQPN2 ;;ALB-CIOFO/ECF -  PERIPHERAL NERVES 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 have a peripheral nerve condition or peripheral

 ;; neuropathy?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, provide only diagnoses that pertain to a peripheral nerve condition

 ;; and/or peripheral neuropathy:

 ;;

 ;; 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 a peripheral nerve

 ;; condition and/or peripheral neuropathy, list using above format: ___________

 ;;

 ;; ____________________________________________________________________________

 ;;

 ;; DEFINITIONS: For VA purposes, neuralgia indicates a condition characterized

 ;; by a dull and intermittent pain of typical distribution so as to identify

 ;; the nerve, while neuritis is characterized by loss of reflexes, muscle

 ;; atrophy, sensory disturbances and constant pain, at times excruciating.

 ;;^TOF^

 ;; 2. Medical history

 ;;

 ;; a. Describe the history (including onset and course) of the Veteran's

 ;; peripheral nerve condition (brief summary): ________________________________

 ;;

 ;; b.  Dominant hand

 ;; ___ Right   ___ Left   ___ Ambidextrous

 ;;

 ;; 3. Symptoms

 ;;

 ;; a. Does the Veteran have any symptoms attributable to any peripheral nerve

 ;; conditions?

 ;; ___ Yes   ___ No

 ;; If yes, indicate symptoms' location and severity (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

 ;;    Right lower extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;    Left lower extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;

 ;; Intermittent pain (usually dull)

 ;;    Right upper extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;    Left upper extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;    Right lower extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;    Left lower extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;

 ;; Paresthesias and/or dysesthesias

 ;;    Right upper extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;    Left upper extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;    Right lower extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;    Left lower extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;

 ;; Numbness

 ;;    Right upper extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;    Left upper extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;    Right lower extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;    Left lower extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 ;;^TOF^

 ;; b. ___ Other symptoms(describe symptoms, location and severity):____________

 ;; ____________________________________________________________________________

 ;;

 ;; 4. 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

 ;;    Grip:            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

 ;;    Pinch (thumb to index finger):

 ;;                     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

 ;;    Knee 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

 ;;    Ankle plantar 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

 ;;    Ankle dorsiflexion:

 ;;                     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: ___________________________

 ;; For each instance of muscle atrophy, provide measurements in centimeters

 ;; of normal side and atrophied side, measured at maximum muscle bulk:

 ;;    Normal side: _____ cm.     Atrophied side: _____ cm.

 ;;^TOF^

 ;; 5. 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+

 ;;    Knee:             Right:   __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 ;;                      Left:    __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 ;;    Ankle:            Right:   __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 ;;                      Left:    __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 ;; 6. Sensory exam

 ;;

 ;; Indicate results for sensation testing for light touch:

 ;;

 ;; ___ 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

 ;;

 ;;    Upper anterior thigh (L2):   Right: ___ Normal  ___ Decreased  ___ Absent

 ;;                                 Left:  ___ Normal  ___ Decreased  ___ Absent

 ;;

 ;;    Thigh/knee (L3/4):           Right: ___ Normal  ___ Decreased  ___ Absent

 ;;                                 Left:  ___ Normal  ___ Decreased  ___ Absent

 ;;

 ;;    Lower leg/ankle (L4/L5/S1):  Right: ___ Normal  ___ Decreased  ___ Absent

 ;;                                 Left:  ___ Normal  ___ Decreased  ___ Absent

 ;;

 ;;    Foot/toes (L5):              Right: ___ Normal  ___ Decreased  ___ Absent

 ;;                                 Left:  ___ Normal  ___ Decreased  ___ Absent

 ;;

 ;;    Other sensory findings, if any: _________________________________________

 ;;^TOF^

 ;; 7. Trophic changes

 ;;

 ;; Does the Veteran have trophic changes (characterized by loss of extremity

 ;; hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, describe: __________________________________________________________

 ;;

 ;; 8. Gait

 ;;

 ;; Is the Veteran's gait normal?

 ;; ___ Yes   ___ No

 ;; 

 ;; If no, describe abnormal gait: _____________________________________________

 ;; Provide etiology of abnormal gait: _________________________________________

 ;;

 ;;9. Special tests for median nerve

 ;;

 ;; Were special tests indicated and performed for median nerve evaluation?

 ;; ___ Yes   ___ No

 ;;

 ;; If yes, indicate results:

 ;;     Phalen's sign: Right:   ___ Positive    ___ Negative

 ;;                    Left:    ___ Positive    ___ Negative

 ;;

 ;;     Tinel's sign:  Right:   ___ Positive    ___ Negative

 ;;                    Left:    ___ Positive    ___ Negative

 ;;^TOF^

 ;; 10. Nerves Affected: Severity evaluation for upper extremity nerves and

 ;; radicular groups

 ;;

 ;; Based on symptoms and findings from this exam, complete the following

 ;; section to provide an estimation of the severity of the Veteran's peripheral

 ;; neuropathy. This summary provides useful information for VA purposes.

 ;;

 ;; NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree of

 ;; lost or impaired function substantially less than the description of

 ;; complete paralysis that is given with each nerve.

 ;;

 ;; If the nerve is completely paralyzed, check the box for "complete

 ;; paralysis". If the nerve is not completely paralyzed, check the box for

 ;; "incomplete paralysis" and indicate severity. For VA purposes, when nerve

 ;; impairment is wholly sensory, the evaluation should be mild, or at most,

 ;; moderate.

 ;;

 Q

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---DVBCQPN2   10270     printed  Mar 13, 2025@20:52:28                                                                                                                                                                                                   Page 2

DVBCQPN2  ;;ALB-CIOFO/ECF -  PERIPHERAL NERVES 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 (VA) for

 +3       ;; disability benefits.  VA will consider the information you provide on this

 +4       ;; questionnaire as part of their evaluation in processing the Veteran's claim.

 +5       ;;

 +6       ;; 1. Diagnosis

 +7       ;;

 +8       ;; Does the Veteran have a peripheral nerve condition or peripheral

 +9       ;; neuropathy?

 +10      ;; ___ Yes   ___ No

 +11      ;;

 +12      ;; If yes, provide only diagnoses that pertain to a peripheral nerve condition

 +13      ;; and/or peripheral neuropathy:

 +14      ;;

 +15      ;; Diagnosis #1: ____________________

 +16      ;; ICD code: ________________________

 +17      ;; Date of diagnosis: _______________

 +18      ;;

 +19      ;; Diagnosis #2: ____________________

 +20      ;; ICD code: ________________________

 +21      ;; Date of diagnosis: _______________

 +22      ;;

 +23      ;; Diagnosis #3: ____________________

 +24      ;; ICD code: ________________________

 +25      ;; Date of diagnosis: _______________

 +26      ;;

 +27      ;; If there are additional diagnoses that pertain to a peripheral nerve

 +28      ;; condition and/or peripheral neuropathy, list using above format: ___________

 +29      ;;

 +30      ;; ____________________________________________________________________________

 +31      ;;

 +32      ;; DEFINITIONS: For VA purposes, neuralgia indicates a condition characterized

 +33      ;; by a dull and intermittent pain of typical distribution so as to identify

 +34      ;; the nerve, while neuritis is characterized by loss of reflexes, muscle

 +35      ;; atrophy, sensory disturbances and constant pain, at times excruciating.

 +36      ;;^TOF^

 +37      ;; 2. Medical history

 +38      ;;

 +39      ;; a. Describe the history (including onset and course) of the Veteran's

 +40      ;; peripheral nerve condition (brief summary): ________________________________

 +41      ;;

 +42      ;; b.  Dominant hand

 +43      ;; ___ Right   ___ Left   ___ Ambidextrous

 +44      ;;

 +45      ;; 3. Symptoms

 +46      ;;

 +47      ;; a. Does the Veteran have any symptoms attributable to any peripheral nerve

 +48      ;; conditions?

 +49      ;; ___ Yes   ___ No

 +50      ;; If yes, indicate symptoms' location and severity (check all that apply):

 +51      ;;

 +52      ;; Constant pain (may be excruciating at times)

 +53      ;;    Right upper extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 +54      ;;    Left upper extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 +55      ;;    Right lower extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 +56      ;;    Left lower extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 +57      ;;

 +58      ;; Intermittent pain (usually dull)

 +59      ;;    Right upper extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 +60      ;;    Left upper extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 +61      ;;    Right lower extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 +62      ;;    Left lower extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 +63      ;;

 +64      ;; Paresthesias and/or dysesthesias

 +65      ;;    Right upper extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 +66      ;;    Left upper extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 +67      ;;    Right lower extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 +68      ;;    Left lower extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 +69      ;;

 +70      ;; Numbness

 +71      ;;    Right upper extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 +72      ;;    Left upper extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 +73      ;;    Right lower extremity: ___ None   ___ Mild   ___ Moderate   ___ Severe

 +74      ;;    Left lower extremity:  ___ None   ___ Mild   ___ Moderate   ___ Severe

 +75      ;;^TOF^

 +76      ;; b. ___ Other symptoms(describe symptoms, location and severity):____________

 +77      ;; ____________________________________________________________________________

 +78      ;;

 +79      ;; 4. Muscle strength testing

 +80      ;;

 +81      ;; a. Rate strength according to the following scale:

 +82      ;;       0/5 No muscle movement

 +83      ;;       1/5 Palpable or visible muscle contraction, but no joint movement

 +84      ;;       2/5 Active movement with gravity eliminated

 +85      ;;       3/5 Active movement against gravity

 +86      ;;       4/5 Active movement against some resistance

 +87      ;;       5/5 Normal strength

 +88      ;;

 +89      ;; ___ All normal

 +90      ;;

 +91      ;;    Elbow flexion:   Right:  __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +92      ;;                     Left:   __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +93      ;;    Elbow extension: Right:  __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +94      ;;                     Left:   __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +95      ;;    Wrist flexion:   Right:  __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +96      ;;                     Left:   __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +97      ;;    Wrist extension: Right:  __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +98      ;;                     Left:   __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +99      ;;    Grip:            Right:  __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +100     ;;                     Left:   __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +101     ;;    Pinch (thumb to index finger):

 +102     ;;                     Right:  __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +103     ;;                     Left:   __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +104     ;;    Knee extension:  Right:  __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +105     ;;                     Left:   __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +106     ;;    Ankle plantar flexion:

 +107     ;;                     Right:  __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +108     ;;                     Left:   __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +109     ;;    Ankle dorsiflexion:

 +110     ;;                     Right:  __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +111     ;;                     Left:   __ 5/5  __ 4/5  __ 3/5  __ 2/5  __ 1/5  __0/5

 +112     ;;

 +113     ;; b. Does the Veteran have muscle atrophy?

 +114     ;; ___ Yes   ___ No

 +115     ;;

 +116     ;; If muscle atrophy is present, indicate location: ___________________________

 +117     ;; For each instance of muscle atrophy, provide measurements in centimeters

 +118     ;; of normal side and atrophied side, measured at maximum muscle bulk:

 +119     ;;    Normal side: _____ cm.     Atrophied side: _____ cm.

 +120     ;;^TOF^

 +121     ;; 5. Reflex exam

 +122     ;;

 +123     ;; Rate deep tendon reflexes (DTRs) according to the following scale:

 +124     ;;    0  Absent

 +125     ;;    1+ Hypoactive

 +126     ;;    2+ Normal

 +127     ;;    3+ Hyperactive without clonus

 +128     ;;    4+ Hyperactive with clonus

 +129     ;;

 +130     ;; ___ All normal

 +131     ;;

 +132     ;;    Biceps:           Right:   __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 +133     ;;                      Left:    __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 +134     ;;    Triceps:          Right:   __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 +135     ;;                      Left:    __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 +136     ;;    Brachioradialis:  Right:   __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 +137     ;;                      Left:    __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 +138     ;;    Knee:             Right:   __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 +139     ;;                      Left:    __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 +140     ;;    Ankle:            Right:   __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 +141     ;;                      Left:    __ 0   __ 1+   ___ 2+   ___ 3+   ___ 4+

 +142     ;; 6. Sensory exam

 +143     ;;

 +144     ;; Indicate results for sensation testing for light touch:

 +145     ;;

 +146     ;; ___ All normal

 +147     ;;

 +148     ;;    Shoulder area (C5):          Right: ___ Normal  ___ Decreased  ___ Absent

 +149     ;;                                 Left:  ___ Normal  ___ Decreased  ___ Absent

 +150     ;;

 +151     ;;    Inner/outer forearm (C6/T1): Right: ___ Normal  ___ Decreased  ___ Absent

 +152     ;;                                 Left:  ___ Normal  ___ Decreased  ___ Absent

 +153     ;;

 +154     ;;    Hand/fingers (C6-8):         Right: ___ Normal  ___ Decreased  ___ Absent

 +155     ;;                                 Left:  ___ Normal  ___ Decreased  ___ Absent

 +156     ;;

 +157     ;;    Upper anterior thigh (L2):   Right: ___ Normal  ___ Decreased  ___ Absent

 +158     ;;                                 Left:  ___ Normal  ___ Decreased  ___ Absent

 +159     ;;

 +160     ;;    Thigh/knee (L3/4):           Right: ___ Normal  ___ Decreased  ___ Absent

 +161     ;;                                 Left:  ___ Normal  ___ Decreased  ___ Absent

 +162     ;;

 +163     ;;    Lower leg/ankle (L4/L5/S1):  Right: ___ Normal  ___ Decreased  ___ Absent

 +164     ;;                                 Left:  ___ Normal  ___ Decreased  ___ Absent

 +165     ;;

 +166     ;;    Foot/toes (L5):              Right: ___ Normal  ___ Decreased  ___ Absent

 +167     ;;                                 Left:  ___ Normal  ___ Decreased  ___ Absent

 +168     ;;

 +169     ;;    Other sensory findings, if any: _________________________________________

 +170     ;;^TOF^

 +171     ;; 7. Trophic changes

 +172     ;;

 +173     ;; Does the Veteran have trophic changes (characterized by loss of extremity

 +174     ;; hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy?

 +175     ;; ___ Yes   ___ No

 +176     ;;

 +177     ;; If yes, describe: __________________________________________________________

 +178     ;;

 +179     ;; 8. Gait

 +180     ;;

 +181     ;; Is the Veteran's gait normal?

 +182     ;; ___ Yes   ___ No

 +183     ;; 

 +184     ;; If no, describe abnormal gait: _____________________________________________

 +185     ;; Provide etiology of abnormal gait: _________________________________________

 +186     ;;

 +187     ;;9. Special tests for median nerve

 +188     ;;

 +189     ;; Were special tests indicated and performed for median nerve evaluation?

 +190     ;; ___ Yes   ___ No

 +191     ;;

 +192     ;; If yes, indicate results:

 +193     ;;     Phalen's sign: Right:   ___ Positive    ___ Negative

 +194     ;;                    Left:    ___ Positive    ___ Negative

 +195     ;;

 +196     ;;     Tinel's sign:  Right:   ___ Positive    ___ Negative

 +197     ;;                    Left:    ___ Positive    ___ Negative

 +198     ;;^TOF^

 +199     ;; 10. Nerves Affected: Severity evaluation for upper extremity nerves and

 +200     ;; radicular groups

 +201     ;;

 +202     ;; Based on symptoms and findings from this exam, complete the following

 +203     ;; section to provide an estimation of the severity of the Veteran's peripheral

 +204     ;; neuropathy. This summary provides useful information for VA purposes.

 +205     ;;

 +206     ;; NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree of

 +207     ;; lost or impaired function substantially less than the description of

 +208     ;; complete paralysis that is given with each nerve.

 +209     ;;

 +210     ;; If the nerve is completely paralyzed, check the box for "complete

 +211     ;; paralysis". If the nerve is not completely paralyzed, check the box for

 +212     ;; "incomplete paralysis" and indicate severity. For VA purposes, when nerve

 +213     ;; impairment is wholly sensory, the evaluation should be mild, or at most,

 +214     ;; moderate.

 +215     ;;

 +216      QUIT