- DVBCQPN3 ;;ALB-CIOFO/ECF - PERIPHERAL NERVES QUESTIONNAIRE (continued); 5/15/2011
- ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
- ;
- TXT ;
- ;;
- ;; Indicate affected nerves, side affected and severity of condition:
- ;;
- ;; a. Radial nerve (musculospiral nerve)
- ;; Note: Complete paralysis (hand and fingers drop, wrist and fingers
- ;; flexed; cannot extend hand at wrist, extend proximal phalanges
- ;; of fingers, extend thumb or make lateral movement of wrist;
- ;; supination of hand, elbow extension and flexion weak, hand grip
- ;; impaired)
- ;;
- ;; ___ Right:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; ___ Left:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;^TOF^
- ;; b. Median nerve
- ;; Note: Complete paralysis (hand inclined to the ulnar side, index and
- ;; middle fingers extended, atrophy of thenar eminence, cannot make
- ;; fist, defective opposition of thumb, cannot flex distal phalanx of
- ;; thumb; wrist flexion weak)
- ;; ___Right:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; ___ Left:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; c. Ulnar nerve
- ;; Note: Complete paralysis ("griffin claw" deformity, atrophy in dorsal
- ;; interspaces, thenar and hypothenar eminences; cannot extend ring and
- ;; little finger, cannot spread fingers, cannot adduct the thumb;
- ;; wrist flexion weakened)
- ;; ___Right:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; ___ Left:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;^TOF^
- ;; d. Musculocutaneous nerve
- ;; Note: Complete paralysis (weakened flexion of elbow and supination of
- ;; forearm)
- ;; ___Right:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; ___ Left:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; e. Circumflex nerve
- ;; Note: Complete paralysis (innervates deltoid and teres minor; cannot
- ;; abduct arm, outward rotation is weakened)
- ;; ___Right:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; ___ Left:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;^TOF^
- ;; f. Long thoracic nerve
- ;; Note: Complete paralysis (inability to raise arm above shoulder level,
- ;; winged scapula deformity)
- ;; ___Right:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; ___ Left:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; g. Upper radicular group (5th & 6th cervicals)
- ;; Note: Complete paralysis (all shoulder and elbow movements lost; hand
- ;; and wrist movements not affected)
- ;; ___Right:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; ___ Left:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;^TOF^
- ;; h. Middle radicular group
- ;; Note: Complete paralysis (adduction, abduction, rotation of arm,
- ;; flexion of elbow and extension of wrist lost)
- ;; ___Right:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; ___ Left:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; i. Lower radicular group
- ;; Note: Complete paralysis (intrinsic hand muscles, wrist and finger
- ;; flexors paralyzed; substantial loss of use of hand)
- ;; ___Right:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;
- ;; ___ Left:
- ;; ___ Normal
- ;; ___ Incomplete paralysis
- ;; ___ Complete paralysis
- ;; If Incomplete paralysis is checked, indicate severity:
- ;; ___ Mild ___ Moderate ___ Severe
- ;;^TOF^
- ;;
- Q
- --- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQPN3 6344 printed Mar 13, 2025@20:52:29 Page 2
- DVBCQPN3 ;;ALB-CIOFO/ECF - PERIPHERAL NERVES QUESTIONNAIRE (continued); 5/15/2011
- +1 ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
- +2 ;
- TXT ;
- +1 ;;
- +2 ;; Indicate affected nerves, side affected and severity of condition:
- +3 ;;
- +4 ;; a. Radial nerve (musculospiral nerve)
- +5 ;; Note: Complete paralysis (hand and fingers drop, wrist and fingers
- +6 ;; flexed; cannot extend hand at wrist, extend proximal phalanges
- +7 ;; of fingers, extend thumb or make lateral movement of wrist;
- +8 ;; supination of hand, elbow extension and flexion weak, hand grip
- +9 ;; impaired)
- +10 ;;
- +11 ;; ___ Right:
- +12 ;; ___ Normal
- +13 ;; ___ Incomplete paralysis
- +14 ;; ___ Complete paralysis
- +15 ;; If Incomplete paralysis is checked, indicate severity:
- +16 ;; ___ Mild ___ Moderate ___ Severe
- +17 ;;
- +18 ;; ___ Left:
- +19 ;; ___ Normal
- +20 ;; ___ Incomplete paralysis
- +21 ;; ___ Complete paralysis
- +22 ;; If Incomplete paralysis is checked, indicate severity:
- +23 ;; ___ Mild ___ Moderate ___ Severe
- +24 ;;^TOF^
- +25 ;; b. Median nerve
- +26 ;; Note: Complete paralysis (hand inclined to the ulnar side, index and
- +27 ;; middle fingers extended, atrophy of thenar eminence, cannot make
- +28 ;; fist, defective opposition of thumb, cannot flex distal phalanx of
- +29 ;; thumb; wrist flexion weak)
- +30 ;; ___Right:
- +31 ;; ___ Normal
- +32 ;; ___ Incomplete paralysis
- +33 ;; ___ Complete paralysis
- +34 ;; If Incomplete paralysis is checked, indicate severity:
- +35 ;; ___ Mild ___ Moderate ___ Severe
- +36 ;;
- +37 ;; ___ Left:
- +38 ;; ___ Normal
- +39 ;; ___ Incomplete paralysis
- +40 ;; ___ Complete paralysis
- +41 ;; If Incomplete paralysis is checked, indicate severity:
- +42 ;; ___ Mild ___ Moderate ___ Severe
- +43 ;;
- +44 ;; c. Ulnar nerve
- +45 ;; Note: Complete paralysis ("griffin claw" deformity, atrophy in dorsal
- +46 ;; interspaces, thenar and hypothenar eminences; cannot extend ring and
- +47 ;; little finger, cannot spread fingers, cannot adduct the thumb;
- +48 ;; wrist flexion weakened)
- +49 ;; ___Right:
- +50 ;; ___ Normal
- +51 ;; ___ Incomplete paralysis
- +52 ;; ___ Complete paralysis
- +53 ;; If Incomplete paralysis is checked, indicate severity:
- +54 ;; ___ Mild ___ Moderate ___ Severe
- +55 ;;
- +56 ;; ___ Left:
- +57 ;; ___ Normal
- +58 ;; ___ Incomplete paralysis
- +59 ;; ___ Complete paralysis
- +60 ;; If Incomplete paralysis is checked, indicate severity:
- +61 ;; ___ Mild ___ Moderate ___ Severe
- +62 ;;^TOF^
- +63 ;; d. Musculocutaneous nerve
- +64 ;; Note: Complete paralysis (weakened flexion of elbow and supination of
- +65 ;; forearm)
- +66 ;; ___Right:
- +67 ;; ___ Normal
- +68 ;; ___ Incomplete paralysis
- +69 ;; ___ Complete paralysis
- +70 ;; If Incomplete paralysis is checked, indicate severity:
- +71 ;; ___ Mild ___ Moderate ___ Severe
- +72 ;;
- +73 ;; ___ Left:
- +74 ;; ___ Normal
- +75 ;; ___ Incomplete paralysis
- +76 ;; ___ Complete paralysis
- +77 ;; If Incomplete paralysis is checked, indicate severity:
- +78 ;; ___ Mild ___ Moderate ___ Severe
- +79 ;;
- +80 ;; e. Circumflex nerve
- +81 ;; Note: Complete paralysis (innervates deltoid and teres minor; cannot
- +82 ;; abduct arm, outward rotation is weakened)
- +83 ;; ___Right:
- +84 ;; ___ Normal
- +85 ;; ___ Incomplete paralysis
- +86 ;; ___ Complete paralysis
- +87 ;; If Incomplete paralysis is checked, indicate severity:
- +88 ;; ___ Mild ___ Moderate ___ Severe
- +89 ;;
- +90 ;; ___ Left:
- +91 ;; ___ Normal
- +92 ;; ___ Incomplete paralysis
- +93 ;; ___ Complete paralysis
- +94 ;; If Incomplete paralysis is checked, indicate severity:
- +95 ;; ___ Mild ___ Moderate ___ Severe
- +96 ;;^TOF^
- +97 ;; f. Long thoracic nerve
- +98 ;; Note: Complete paralysis (inability to raise arm above shoulder level,
- +99 ;; winged scapula deformity)
- +100 ;; ___Right:
- +101 ;; ___ Normal
- +102 ;; ___ Incomplete paralysis
- +103 ;; ___ Complete paralysis
- +104 ;; If Incomplete paralysis is checked, indicate severity:
- +105 ;; ___ Mild ___ Moderate ___ Severe
- +106 ;;
- +107 ;; ___ Left:
- +108 ;; ___ Normal
- +109 ;; ___ Incomplete paralysis
- +110 ;; ___ Complete paralysis
- +111 ;; If Incomplete paralysis is checked, indicate severity:
- +112 ;; ___ Mild ___ Moderate ___ Severe
- +113 ;;
- +114 ;; g. Upper radicular group (5th & 6th cervicals)
- +115 ;; Note: Complete paralysis (all shoulder and elbow movements lost; hand
- +116 ;; and wrist movements not affected)
- +117 ;; ___Right:
- +118 ;; ___ Normal
- +119 ;; ___ Incomplete paralysis
- +120 ;; ___ Complete paralysis
- +121 ;; If Incomplete paralysis is checked, indicate severity:
- +122 ;; ___ Mild ___ Moderate ___ Severe
- +123 ;;
- +124 ;; ___ Left:
- +125 ;; ___ Normal
- +126 ;; ___ Incomplete paralysis
- +127 ;; ___ Complete paralysis
- +128 ;; If Incomplete paralysis is checked, indicate severity:
- +129 ;; ___ Mild ___ Moderate ___ Severe
- +130 ;;^TOF^
- +131 ;; h. Middle radicular group
- +132 ;; Note: Complete paralysis (adduction, abduction, rotation of arm,
- +133 ;; flexion of elbow and extension of wrist lost)
- +134 ;; ___Right:
- +135 ;; ___ Normal
- +136 ;; ___ Incomplete paralysis
- +137 ;; ___ Complete paralysis
- +138 ;; If Incomplete paralysis is checked, indicate severity:
- +139 ;; ___ Mild ___ Moderate ___ Severe
- +140 ;;
- +141 ;; ___ Left:
- +142 ;; ___ Normal
- +143 ;; ___ Incomplete paralysis
- +144 ;; ___ Complete paralysis
- +145 ;; If Incomplete paralysis is checked, indicate severity:
- +146 ;; ___ Mild ___ Moderate ___ Severe
- +147 ;;
- +148 ;; i. Lower radicular group
- +149 ;; Note: Complete paralysis (intrinsic hand muscles, wrist and finger
- +150 ;; flexors paralyzed; substantial loss of use of hand)
- +151 ;; ___Right:
- +152 ;; ___ Normal
- +153 ;; ___ Incomplete paralysis
- +154 ;; ___ Complete paralysis
- +155 ;; If Incomplete paralysis is checked, indicate severity:
- +156 ;; ___ Mild ___ Moderate ___ Severe
- +157 ;;
- +158 ;; ___ Left:
- +159 ;; ___ Normal
- +160 ;; ___ Incomplete paralysis
- +161 ;; ___ Complete paralysis
- +162 ;; If Incomplete paralysis is checked, indicate severity:
- +163 ;; ___ Mild ___ Moderate ___ Severe
- +164 ;;^TOF^
- +165 ;;
- +166 QUIT
