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Routine: DVBCQPN4

DVBCQPN4.m

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  1. DVBCQPN4 ;;ALB-CIOFO/ECF -  PERIPHERAL NERVES QUESTIONNAIRE (continued); 5/15/2011
  1.  ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; 11. Nerves Affected: Severity evaluation for lower extremity nerves
  1.  ;;
  1.  ;; Based on symptoms and findings from this exam, complete the following
  1.  ;; section to provide an estimation of the severity of the Veteran's
  1.  ;; peripheral neuropathy. This summary provides useful information for VA
  1.  ;; purposes.
  1.  ;;
  1.  ;; NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree
  1.  ;; of lost or impaired function substantially less than the description of
  1.  ;; complete paralysis that is given with each nerve.
  1.  ;;
  1.  ;; If the nerve is completely paralyzed, check the box for "complete
  1.  ;; paralysis." If the nerve is not completely paralyzed, check the box for
  1.  ;; "incomplete paralysis" and indicate severity. For VA purposes, when nerve
  1.  ;; impairment is wholly sensory, the evaluation should be mild, or at most,
  1.  ;; moderate.
  1.  ;;
  1.  ;; Indicate affected nerves, side affected and severity of condition:
  1.  ;; 
  1.  ;; a. Sciatic nerve
  1.  ;;    Note: Complete paralysis (foot dangles and drops, no active movement
  1.  ;;    of muscles below the knee, flexion of knee weakened or lost)
  1.  ;;    ___ Right:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Moderately Severe
  1.  ;;            ___ Severe, with marked muscular atrophy
  1.  ;;
  1.  ;;    ___ Left:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Moderately Severe
  1.  ;;            ___ Severe, with marked muscular atrophy
  1.  ;;^TOF^
  1.  ;; b. External popliteal (common peroneal) nerve
  1.  ;;    Note: Complete paralysis (foot drop, cannot dorsiflex foot or extend
  1.  ;;    toes; dorsum of foot and toes are numb)
  1.  ;;    ___ Right:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;    ___ Left:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;; c. Musculocutaneous (superficial peroneal) nerve
  1.  ;;    Note: Complete paralysis (eversion of foot weakened)
  1.  ;;    ___ Right:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;    ___ Left:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;; d. Anterior tibial (deep peroneal) nerve
  1.  ;;    Note: Complete paralysis (dorsiflexion of foot lost)
  1.  ;;    ___ Right:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;    ___ Left:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;^TOF^
  1.  ;; e. Internal popliteal (tibial) nerve
  1.  ;;    Note: Complete paralysis (plantar flexion lost, frank adduction of
  1.  ;;    foot impossible, flexion and separation of toes abolished; no muscle
  1.  ;;    in sole can move; in lesions of the nerve high in popliteal fossa,
  1.  ;;    plantar flexion of foot is lost)
  1.  ;;    ___ Right:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;    ___ Left:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;; f. Posterior tibial nerve
  1.  ;;    Note: Complete paralysis (paralysis of all muscles of sole of foot,
  1.  ;;    frequently with painful paralysis of a causalgic nature; loss of toe
  1.  ;;    flexion; adduction weakened; plantar flexion impaired)
  1.  ;;    ___ Right:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;    ___ Left:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;^TOF^
  1.  ;; g. Anterior crural (femoral) nerve
  1.  ;;    Note: Complete paralysis (paralysis of quadriceps extensor muscles)
  1.  ;;    ___ Right:
  1.  ;;        ___ Normal 
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;    ___ Left:
  1.  ;;        ___ Normal 
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;; h. Internal saphenous nerve
  1.  ;;    ___ Right:
  1.  ;;        ___ Normal 
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;    ___ Left:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;; i. Obturator nerve
  1.  ;;     ___ Right:
  1.  ;;         ___ Normal
  1.  ;;         ___ Incomplete paralysis
  1.  ;;         ___ Complete paralysis
  1.  ;;         If Incomplete paralysis is checked, indicate severity:
  1.  ;;             ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;     ___ Left:
  1.  ;;         ___ Normal
  1.  ;;         ___ Incomplete paralysis
  1.  ;;         ___ Complete paralysis
  1.  ;;         If Incomplete paralysis is checked, indicate severity:
  1.  ;;             ___ Mild   ___ Moderate   ___ Severe
  1.  ;;^TOF^
  1.  ;; j. External cutaneous nerve of the thigh
  1.  ;;    ___ Right:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;    ___ Left:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;; k. Illio-inguinal nerve
  1.  ;;    ___ Right:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;;    ___ Left:
  1.  ;;        ___ Normal
  1.  ;;        ___ Incomplete paralysis
  1.  ;;        ___ Complete paralysis
  1.  ;;        If Incomplete paralysis is checked, indicate severity:
  1.  ;;            ___ Mild   ___ Moderate   ___ Severe
  1.  ;;
  1.  ;; 12. Assistive devices
  1.  ;;
  1.  ;; a. Does the Veteran use any assistive devices 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.  ;;^TOF^
  1.  ;; 13. Remaining effective function of the extremities
  1.  ;;
  1.  ;; Due to peripheral nerve conditions, is there functional impairment of an
  1.  ;; extremity such that no effective function remains other than that which
  1.  ;; would be equally well served by an amputation with prosthesis? (Functions
  1.  ;; of the upper extremity include grasping, manipulation, etc., while functions
  1.  ;; for the lower extremity include balance and propulsion, etc.)
  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    ___ Right lower    ___ Left lower
  1.  ;;
  1.  ;; For each checked extremity, describe loss of effective function, identify
  1.  ;; the condition causing loss of function, and provide specific examples
  1.  ;; (brief summary):____________________________________________________________
  1.  ;;
  1.  ;; 14. 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.  ;;
  1.  ;; 15. Diagnostic testing
  1.  ;;
  1.  ;; For the purpose of this examination, electromyography (EMG) studies are
  1.  ;; usually rarely required to diagnose specific peripheral nerve conditions in
  1.  ;; the appropriate clinical setting. If EMG studies are in the medical record
  1.  ;; and reflect the Veteran's current condition, repeat studies are not
  1.  ;; indicated.
  1.  ;;^TOF^
  1.  ;; a. Have EMG studies been performed?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;;  Extremities tested:
  1.  ;;    ___ Right upper extremity  Results: __Normal   __ Abnormal  Date: _______
  1.  ;;    ___ Left upper extremity   Results: __Normal   __ Abnormal  Date: _______
  1.  ;;    ___ Right lower extremity  Results: __Normal   __ Abnormal  Date: _______
  1.  ;;    ___ Left lower extremity   Results: __Normal   __ Abnormal  Date: _______
  1.  ;; If abnormal, describe: _____________________________________________________
  1.  ;;
  1.  ;; b. 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.  ;; 16. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's peripheral nerve condition and/or peripheral neuropathy
  1.  ;; impact his or her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, describe impact of each of the Veteran's peripheral nerve and/or
  1.  ;; peripheral neuropathy condition(s), providing one or more examples: ________
  1.  ;;
  1.  ;;_____________________________________________________________________________
  1.  ;;
  1.  ;; 17. 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