DVBCQPN4 ;;ALB-CIOFO/ECF - PERIPHERAL NERVES QUESTIONNAIRE (continued); 5/15/2011
;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
;
TXT ;
;;
;; 11. Nerves Affected: Severity evaluation for lower extremity nerves
;;
;; 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.
;;
;; Indicate affected nerves, side affected and severity of condition:
;;
;; a. Sciatic nerve
;; Note: Complete paralysis (foot dangles and drops, no active movement
;; of muscles below the knee, flexion of knee weakened or lost)
;; ___ Right:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Moderately Severe
;; ___ Severe, with marked muscular atrophy
;;
;; ___ Left:
;; ___ Normal
;; ___ Incomplete paralysis
;; ___ Complete paralysis
;; If Incomplete paralysis is checked, indicate severity:
;; ___ Mild ___ Moderate ___ Moderately Severe
;; ___ Severe, with marked muscular atrophy
;;^TOF^
;; b. External popliteal (common peroneal) nerve
;; Note: Complete paralysis (foot drop, cannot dorsiflex foot or extend
;; toes; dorsum of foot and toes are numb)
;; ___ 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. Musculocutaneous (superficial peroneal) nerve
;; Note: Complete paralysis (eversion of foot 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
;;
;; d. Anterior tibial (deep peroneal) nerve
;; Note: Complete paralysis (dorsiflexion of foot 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
;;^TOF^
;; e. Internal popliteal (tibial) nerve
;; Note: Complete paralysis (plantar flexion lost, frank adduction of
;; foot impossible, flexion and separation of toes abolished; no muscle
;; in sole can move; in lesions of the nerve high in popliteal fossa,
;; plantar flexion of foot is 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
;;
;; f. Posterior tibial nerve
;; Note: Complete paralysis (paralysis of all muscles of sole of foot,
;; frequently with painful paralysis of a causalgic nature; loss of toe
;; flexion; adduction weakened; plantar flexion 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^
;; g. Anterior crural (femoral) nerve
;; Note: Complete paralysis (paralysis of quadriceps extensor muscles)
;; ___ 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
;;
;; h. Internal saphenous nerve
;; ___ 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. Obturator nerve
;; ___ 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^
;; j. External cutaneous nerve of the thigh
;; ___ 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
;;
;; k. Illio-inguinal nerve
;; ___ 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
;;
;; 12. Assistive devices
;;
;; a. Does the Veteran use any assistive devices as a normal mode of
;; locomotion, although occasional locomotion by other methods may be possible?
;; ___ Yes ___ No
;;
;; If yes, identify assistive device(s) used (check all that apply and indicate
;; frequency):
;; __ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
;; __ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
;; __ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
;; __ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
;; __ Walker Frequency of use: __ Occasional __ Regular __ Constant
;; __ Other: ________________________________________________________________
;; Frequency of use: __ Occasional __ Regular __ Constant
;;
;; b. If the Veteran uses any assistive devices, specify the condition and
;; identify the assistive device used for each condition: _____________________
;;^TOF^
;; 13. Remaining effective function of the extremities
;;
;; Due to peripheral nerve conditions, is there functional impairment of an
;; extremity such that no effective function remains other than that which
;; would be equally well served by an amputation with prosthesis? (Functions
;; of the upper extremity include grasping, manipulation, etc., while functions
;; for the lower extremity include balance and propulsion, etc.)
;; ___ Yes, functioning is so diminished that amputation with prosthesis would
;; equally serve the Veteran.
;; ___ No
;; If yes, indicate extremity(ies) (check all extremities for which this
;; applies):
;; ___ Right upper ___ Left upper ___ Right lower ___ Left lower
;;
;; For each checked extremity, describe loss of effective function, identify
;; the condition causing loss of function, and provide specific examples
;; (brief summary):____________________________________________________________
;;
;; 14. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;;
;; a. Does the Veteran have any scars (surgical or otherwise) related to any
;; conditions or to the treatment of any conditions listed in the Diagnosis
;; section above?
;; ___ Yes ___ No
;; If yes, are any of the scars painful and/or unstable, or is the total area
;; of all related scars greater than 39 square cm (6 square inches)?
;; ___ Yes ___ No
;; If yes, also complete a Scars Questionnaire.
;;
;; b. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs or symptoms?
;; ___ Yes ___ No
;;
;; If yes, describe (brief summary): __________________________________________
;;
;; 15. Diagnostic testing
;;
;; For the purpose of this examination, electromyography (EMG) studies are
;; usually rarely required to diagnose specific peripheral nerve conditions in
;; the appropriate clinical setting. If EMG studies are in the medical record
;; and reflect the Veteran's current condition, repeat studies are not
;; indicated.
;;^TOF^
;; a. Have EMG studies been performed?
;; ___ Yes ___ No
;;
;; Extremities tested:
;; ___ Right upper extremity Results: __Normal __ Abnormal Date: _______
;; ___ Left upper extremity Results: __Normal __ Abnormal Date: _______
;; ___ Right lower extremity Results: __Normal __ Abnormal Date: _______
;; ___ Left lower extremity Results: __Normal __ Abnormal Date: _______
;; If abnormal, describe: _____________________________________________________
;;
;; b. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;;
;; If yes, provide type of test or procedure, date and results (brief summary):
;;
;; ____________________________________________________________________________
;;
;; 16. Functional impact
;;
;; Does the Veteran's peripheral nerve condition and/or peripheral neuropathy
;; impact his or her ability to work?
;; ___ Yes ___ No
;;
;; If yes, describe impact of each of the Veteran's peripheral nerve and/or
;; peripheral neuropathy condition(s), providing one or more examples: ________
;;
;;_____________________________________________________________________________
;;
;; 17. Remarks, if any: _______________________________________________________
;;
;; Physician signature: ____________________________________ Date: ____________
;;
;; Physician printed name: ____________________________________________________
;;
;; Medical license #: _________________________________________________________
;;
;; Physician address: _________________________________________________________
;;
;; Phone: _____________________________ FAX: ______________________________
;;
;; NOTE: VA may request additional medical information, including additional
;; examinations if necessary to complete VA's review of the Veteran's
;; application.
;;
;;^END^
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQPN4 13003 printed Nov 22, 2024@16:58 Page 2
DVBCQPN4 ;;ALB-CIOFO/ECF - PERIPHERAL NERVES QUESTIONNAIRE (continued); 5/15/2011
+1 ;;2.7;AMIE;**167**;Apr 10, 1995;Build 1
+2 ;
TXT ;
+1 ;;
+2 ;; 11. Nerves Affected: Severity evaluation for lower extremity nerves
+3 ;;
+4 ;; Based on symptoms and findings from this exam, complete the following
+5 ;; section to provide an estimation of the severity of the Veteran's
+6 ;; peripheral neuropathy. This summary provides useful information for VA
+7 ;; purposes.
+8 ;;
+9 ;; NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree
+10 ;; of lost or impaired function substantially less than the description of
+11 ;; complete paralysis that is given with each nerve.
+12 ;;
+13 ;; If the nerve is completely paralyzed, check the box for "complete
+14 ;; paralysis." If the nerve is not completely paralyzed, check the box for
+15 ;; "incomplete paralysis" and indicate severity. For VA purposes, when nerve
+16 ;; impairment is wholly sensory, the evaluation should be mild, or at most,
+17 ;; moderate.
+18 ;;
+19 ;; Indicate affected nerves, side affected and severity of condition:
+20 ;;
+21 ;; a. Sciatic nerve
+22 ;; Note: Complete paralysis (foot dangles and drops, no active movement
+23 ;; of muscles below the knee, flexion of knee weakened or lost)
+24 ;; ___ Right:
+25 ;; ___ Normal
+26 ;; ___ Incomplete paralysis
+27 ;; ___ Complete paralysis
+28 ;; If Incomplete paralysis is checked, indicate severity:
+29 ;; ___ Mild ___ Moderate ___ Moderately Severe
+30 ;; ___ Severe, with marked muscular atrophy
+31 ;;
+32 ;; ___ Left:
+33 ;; ___ Normal
+34 ;; ___ Incomplete paralysis
+35 ;; ___ Complete paralysis
+36 ;; If Incomplete paralysis is checked, indicate severity:
+37 ;; ___ Mild ___ Moderate ___ Moderately Severe
+38 ;; ___ Severe, with marked muscular atrophy
+39 ;;^TOF^
+40 ;; b. External popliteal (common peroneal) nerve
+41 ;; Note: Complete paralysis (foot drop, cannot dorsiflex foot or extend
+42 ;; toes; dorsum of foot and toes are numb)
+43 ;; ___ Right:
+44 ;; ___ Normal
+45 ;; ___ Incomplete paralysis
+46 ;; ___ Complete paralysis
+47 ;; If Incomplete paralysis is checked, indicate severity:
+48 ;; ___ Mild ___ Moderate ___ Severe
+49 ;;
+50 ;; ___ Left:
+51 ;; ___ Normal
+52 ;; ___ Incomplete paralysis
+53 ;; ___ Complete paralysis
+54 ;; If Incomplete paralysis is checked, indicate severity:
+55 ;; ___ Mild ___ Moderate ___ Severe
+56 ;;
+57 ;; c. Musculocutaneous (superficial peroneal) nerve
+58 ;; Note: Complete paralysis (eversion of foot weakened)
+59 ;; ___ Right:
+60 ;; ___ Normal
+61 ;; ___ Incomplete paralysis
+62 ;; ___ Complete paralysis
+63 ;; If Incomplete paralysis is checked, indicate severity:
+64 ;; ___ Mild ___ Moderate ___ Severe
+65 ;;
+66 ;; ___ Left:
+67 ;; ___ Normal
+68 ;; ___ Incomplete paralysis
+69 ;; ___ Complete paralysis
+70 ;; If Incomplete paralysis is checked, indicate severity:
+71 ;; ___ Mild ___ Moderate ___ Severe
+72 ;;
+73 ;; d. Anterior tibial (deep peroneal) nerve
+74 ;; Note: Complete paralysis (dorsiflexion of foot lost)
+75 ;; ___ Right:
+76 ;; ___ Normal
+77 ;; ___ Incomplete paralysis
+78 ;; ___ Complete paralysis
+79 ;; If Incomplete paralysis is checked, indicate severity:
+80 ;; ___ Mild ___ Moderate ___ Severe
+81 ;;
+82 ;; ___ Left:
+83 ;; ___ Normal
+84 ;; ___ Incomplete paralysis
+85 ;; ___ Complete paralysis
+86 ;; If Incomplete paralysis is checked, indicate severity:
+87 ;; ___ Mild ___ Moderate ___ Severe
+88 ;;^TOF^
+89 ;; e. Internal popliteal (tibial) nerve
+90 ;; Note: Complete paralysis (plantar flexion lost, frank adduction of
+91 ;; foot impossible, flexion and separation of toes abolished; no muscle
+92 ;; in sole can move; in lesions of the nerve high in popliteal fossa,
+93 ;; plantar flexion of foot is lost)
+94 ;; ___ Right:
+95 ;; ___ Normal
+96 ;; ___ Incomplete paralysis
+97 ;; ___ Complete paralysis
+98 ;; If Incomplete paralysis is checked, indicate severity:
+99 ;; ___ Mild ___ Moderate ___ Severe
+100 ;;
+101 ;; ___ Left:
+102 ;; ___ Normal
+103 ;; ___ Incomplete paralysis
+104 ;; ___ Complete paralysis
+105 ;; If Incomplete paralysis is checked, indicate severity:
+106 ;; ___ Mild ___ Moderate ___ Severe
+107 ;;
+108 ;; f. Posterior tibial nerve
+109 ;; Note: Complete paralysis (paralysis of all muscles of sole of foot,
+110 ;; frequently with painful paralysis of a causalgic nature; loss of toe
+111 ;; flexion; adduction weakened; plantar flexion impaired)
+112 ;; ___ Right:
+113 ;; ___ Normal
+114 ;; ___ Incomplete paralysis
+115 ;; ___ Complete paralysis
+116 ;; If Incomplete paralysis is checked, indicate severity:
+117 ;; ___ Mild ___ Moderate ___ Severe
+118 ;;
+119 ;; ___ Left:
+120 ;; ___ Normal
+121 ;; ___ Incomplete paralysis
+122 ;; ___ Complete paralysis
+123 ;; If Incomplete paralysis is checked, indicate severity:
+124 ;; ___ Mild ___ Moderate ___ Severe
+125 ;;^TOF^
+126 ;; g. Anterior crural (femoral) nerve
+127 ;; Note: Complete paralysis (paralysis of quadriceps extensor muscles)
+128 ;; ___ Right:
+129 ;; ___ Normal
+130 ;; ___ Incomplete paralysis
+131 ;; ___ Complete paralysis
+132 ;; If Incomplete paralysis is checked, indicate severity:
+133 ;; ___ Mild ___ Moderate ___ Severe
+134 ;;
+135 ;; ___ Left:
+136 ;; ___ Normal
+137 ;; ___ Incomplete paralysis
+138 ;; ___ Complete paralysis
+139 ;; If Incomplete paralysis is checked, indicate severity:
+140 ;; ___ Mild ___ Moderate ___ Severe
+141 ;;
+142 ;; h. Internal saphenous nerve
+143 ;; ___ Right:
+144 ;; ___ Normal
+145 ;; ___ Incomplete paralysis
+146 ;; ___ Complete paralysis
+147 ;; If Incomplete paralysis is checked, indicate severity:
+148 ;; ___ Mild ___ Moderate ___ Severe
+149 ;;
+150 ;; ___ Left:
+151 ;; ___ Normal
+152 ;; ___ Incomplete paralysis
+153 ;; ___ Complete paralysis
+154 ;; If Incomplete paralysis is checked, indicate severity:
+155 ;; ___ Mild ___ Moderate ___ Severe
+156 ;;
+157 ;; i. Obturator nerve
+158 ;; ___ Right:
+159 ;; ___ Normal
+160 ;; ___ Incomplete paralysis
+161 ;; ___ Complete paralysis
+162 ;; If Incomplete paralysis is checked, indicate severity:
+163 ;; ___ Mild ___ Moderate ___ Severe
+164 ;;
+165 ;; ___ Left:
+166 ;; ___ Normal
+167 ;; ___ Incomplete paralysis
+168 ;; ___ Complete paralysis
+169 ;; If Incomplete paralysis is checked, indicate severity:
+170 ;; ___ Mild ___ Moderate ___ Severe
+171 ;;^TOF^
+172 ;; j. External cutaneous nerve of the thigh
+173 ;; ___ Right:
+174 ;; ___ Normal
+175 ;; ___ Incomplete paralysis
+176 ;; ___ Complete paralysis
+177 ;; If Incomplete paralysis is checked, indicate severity:
+178 ;; ___ Mild ___ Moderate ___ Severe
+179 ;;
+180 ;; ___ Left:
+181 ;; ___ Normal
+182 ;; ___ Incomplete paralysis
+183 ;; ___ Complete paralysis
+184 ;; If Incomplete paralysis is checked, indicate severity:
+185 ;; ___ Mild ___ Moderate ___ Severe
+186 ;;
+187 ;; k. Illio-inguinal nerve
+188 ;; ___ Right:
+189 ;; ___ Normal
+190 ;; ___ Incomplete paralysis
+191 ;; ___ Complete paralysis
+192 ;; If Incomplete paralysis is checked, indicate severity:
+193 ;; ___ Mild ___ Moderate ___ Severe
+194 ;;
+195 ;; ___ Left:
+196 ;; ___ Normal
+197 ;; ___ Incomplete paralysis
+198 ;; ___ Complete paralysis
+199 ;; If Incomplete paralysis is checked, indicate severity:
+200 ;; ___ Mild ___ Moderate ___ Severe
+201 ;;
+202 ;; 12. Assistive devices
+203 ;;
+204 ;; a. Does the Veteran use any assistive devices as a normal mode of
+205 ;; locomotion, although occasional locomotion by other methods may be possible?
+206 ;; ___ Yes ___ No
+207 ;;
+208 ;; If yes, identify assistive device(s) used (check all that apply and indicate
+209 ;; frequency):
+210 ;; __ Wheelchair Frequency of use: __ Occasional __ Regular __ Constant
+211 ;; __ Brace(s) Frequency of use: __ Occasional __ Regular __ Constant
+212 ;; __ Crutch(es) Frequency of use: __ Occasional __ Regular __ Constant
+213 ;; __ Cane(s) Frequency of use: __ Occasional __ Regular __ Constant
+214 ;; __ Walker Frequency of use: __ Occasional __ Regular __ Constant
+215 ;; __ Other: ________________________________________________________________
+216 ;; Frequency of use: __ Occasional __ Regular __ Constant
+217 ;;
+218 ;; b. If the Veteran uses any assistive devices, specify the condition and
+219 ;; identify the assistive device used for each condition: _____________________
+220 ;;^TOF^
+221 ;; 13. Remaining effective function of the extremities
+222 ;;
+223 ;; Due to peripheral nerve conditions, is there functional impairment of an
+224 ;; extremity such that no effective function remains other than that which
+225 ;; would be equally well served by an amputation with prosthesis? (Functions
+226 ;; of the upper extremity include grasping, manipulation, etc., while functions
+227 ;; for the lower extremity include balance and propulsion, etc.)
+228 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+229 ;; equally serve the Veteran.
+230 ;; ___ No
+231 ;; If yes, indicate extremity(ies) (check all extremities for which this
+232 ;; applies):
+233 ;; ___ Right upper ___ Left upper ___ Right lower ___ Left lower
+234 ;;
+235 ;; For each checked extremity, describe loss of effective function, identify
+236 ;; the condition causing loss of function, and provide specific examples
+237 ;; (brief summary):____________________________________________________________
+238 ;;
+239 ;; 14. Other pertinent physical findings, complications, conditions, signs
+240 ;; and/or symptoms
+241 ;;
+242 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+243 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+244 ;; section above?
+245 ;; ___ Yes ___ No
+246 ;; If yes, are any of the scars painful and/or unstable, or is the total area
+247 ;; of all related scars greater than 39 square cm (6 square inches)?
+248 ;; ___ Yes ___ No
+249 ;; If yes, also complete a Scars Questionnaire.
+250 ;;
+251 ;; b. Does the Veteran have any other pertinent physical findings,
+252 ;; complications, conditions, signs or symptoms?
+253 ;; ___ Yes ___ No
+254 ;;
+255 ;; If yes, describe (brief summary): __________________________________________
+256 ;;
+257 ;; 15. Diagnostic testing
+258 ;;
+259 ;; For the purpose of this examination, electromyography (EMG) studies are
+260 ;; usually rarely required to diagnose specific peripheral nerve conditions in
+261 ;; the appropriate clinical setting. If EMG studies are in the medical record
+262 ;; and reflect the Veteran's current condition, repeat studies are not
+263 ;; indicated.
+264 ;;^TOF^
+265 ;; a. Have EMG studies been performed?
+266 ;; ___ Yes ___ No
+267 ;;
+268 ;; Extremities tested:
+269 ;; ___ Right upper extremity Results: __Normal __ Abnormal Date: _______
+270 ;; ___ Left upper extremity Results: __Normal __ Abnormal Date: _______
+271 ;; ___ Right lower extremity Results: __Normal __ Abnormal Date: _______
+272 ;; ___ Left lower extremity Results: __Normal __ Abnormal Date: _______
+273 ;; If abnormal, describe: _____________________________________________________
+274 ;;
+275 ;; b. Are there any other significant diagnostic test findings and/or results?
+276 ;; ___ Yes ___ No
+277 ;;
+278 ;; If yes, provide type of test or procedure, date and results (brief summary):
+279 ;;
+280 ;; ____________________________________________________________________________
+281 ;;
+282 ;; 16. Functional impact
+283 ;;
+284 ;; Does the Veteran's peripheral nerve condition and/or peripheral neuropathy
+285 ;; impact his or her ability to work?
+286 ;; ___ Yes ___ No
+287 ;;
+288 ;; If yes, describe impact of each of the Veteran's peripheral nerve and/or
+289 ;; peripheral neuropathy condition(s), providing one or more examples: ________
+290 ;;
+291 ;;_____________________________________________________________________________
+292 ;;
+293 ;; 17. Remarks, if any: _______________________________________________________
+294 ;;
+295 ;; Physician signature: ____________________________________ Date: ____________
+296 ;;
+297 ;; Physician printed name: ____________________________________________________
+298 ;;
+299 ;; Medical license #: _________________________________________________________
+300 ;;
+301 ;; Physician address: _________________________________________________________
+302 ;;
+303 ;; Phone: _____________________________ FAX: ______________________________
+304 ;;
+305 ;; NOTE: VA may request additional medical information, including additional
+306 ;; examinations if necessary to complete VA's review of the Veteran's
+307 ;; application.
+308 ;;
+309 ;;^END^
+310 QUIT
