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 ---[H[J[2J[HDVBCQPN2 10270 printed Apr 09, 2024@20:45:49 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
