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Routine: DVBCQSA2

DVBCQSA2.m

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  1. DVBCQSA2 ;;ALB-CIOFO/ECF - SHOULDER AND ARM QUESTIONNAIRE ; 6/15/2011
  1.  ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA)
  1.  ;; for disability benefits.  VA will consider the information you provide on
  1.  ;; this questionnaire as part of their evaluation in processing the Veteran's
  1.  ;; claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;;
  1.  ;; Does the Veteran now have or has he/she ever had a shoulder and/or arm
  1.  ;; condition?
  1.  ;; ___Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide only diagnoses that pertain to shoulder and/or arm
  1.  ;; conditions:
  1.  ;; Diagnosis #1: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;; Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; Diagnosis #2: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;; Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; Diagnosis #3: ___________________
  1.  ;; ICD code:  ______________________
  1.  ;; Date of diagnosis: ______________
  1.  ;; Side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to shoulder and/or arm
  1.  ;; conditions, list using above format: _______________________________________
  1.  ;;
  1.  ;; 2. Medical history
  1.  ;;
  1.  ;; a. Describe the history (including onset and course) of the Veteran's
  1.  ;; shoulder and/or arm condition (brief summary): _____________________________
  1.  ;;
  1.  ;; b. Dominant hand:
  1.  ;; ___ Right   ___ Left   ___ Ambidextrous
  1.  ;;
  1.  ;; 3. Flare-ups
  1.  ;;
  1.  ;; Does the Veteran report that flare-ups impact the function of the shoulder
  1.  ;; and/or arm?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, document the Veteran's description of the impact of flare-ups in his
  1.  ;; or her own words: __________________________________________________________
  1.  ;;^TOF^
  1.  ;; 4. Initial range of motion (ROM) measurements
  1.  ;;
  1.  ;; Measure ROM with a goniometer, rounding each measurement to the nearest
  1.  ;; 5 degrees. During the measurements, document the point at which painful
  1.  ;; motion begins, evidenced by visible behavior such as facial expression,
  1.  ;; wincing, etc. Report initial measurements below.
  1.  ;;
  1.  ;; Following the initial assessment of ROM, perform repetitive use testing.
  1.  ;; For VA purposes, repetitive use testing must be included in all joint
  1.  ;; exams. The VA has determined that 3 repetitions of ROM (at a minimum) can
  1.  ;; serve as a representative test of the effect of repetitive use. After the
  1.  ;; initial measurement, reassess ROM after 3 repetitions. Report post-test
  1.  ;; measurements in section 5.
  1.  ;;
  1.  ;; a. Right shoulder flexion
  1.  ;; Select where flexion ends (normal endpoint is 180 degrees):
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90
  1.  ;; __95   __100  __105  __110  __115  __120  __125  __130  __135
  1.  ;; __140  __145  __150  __155  __160  __165  __170  __175  __180
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;; ___ No objective evidence of painful motion
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90
  1.  ;; __95   __100  __105  __110  __115  __120  __125  __130  __135
  1.  ;; __140  __145  __150  __155  __160  __165  __170  __175  __180
  1.  ;;
  1.  ;; b. Right shoulder abduction
  1.  ;; Select where abduction ends (normal endpoint is 180 degrees):
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90
  1.  ;; __95   __100  __105  __110  __115  __120  __125  __130  __135
  1.  ;; __140  __145  __150  __155  __160  __165  __170  __175  __180
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;; ___ No objective evidence of painful motion
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90
  1.  ;; __95   __100  __105  __110  __115  __120  __125  __130  __135
  1.  ;; __140  __145  __150  __155  __160  __165  __170  __175  __180
  1.  ;;
  1.  ;; c. Left shoulder flexion
  1.  ;; Select where flexion ends (normal endpoint is 180 degrees):
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90
  1.  ;; __95   __100  __105  __110  __115  __120  __125  __130  __135
  1.  ;; __140  __145  __150  __155  __160  __165  __170  __175  __180
  1.  ;;^TOF^ 
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;; ___ No objective evidence of painful motion
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90
  1.  ;; __95   __100  __105  __110  __115  __120  __125  __130  __135
  1.  ;; __140  __145  __150  __155  __160  __165  __170  __175  __180
  1.  ;;
  1.  ;; d. Left shoulder abduction
  1.  ;; Select where abduction ends (normal endpoint is 180 degrees):
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90
  1.  ;; __95   __100  __105  __110  __115  __120  __125  __130  __135
  1.  ;; __140  __145  __150  __155  __160  __165  __170  __175  __180
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;; ___ No objective evidence of painful motion
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90
  1.  ;; __95   __100  __105  __110  __115  __120  __125  __130  __135
  1.  ;; __140  __145  __150  __155  __160  __165  __170  __175  __180
  1.  ;;
  1.  ;; e. If ROM does not conform to the normal range of motion identified above
  1.  ;; but is normal for this Veteran (for reasons other than a shoulder or arm
  1.  ;; condition, such as age, body habitus, neurologic disease), explain:
  1.  ;; ____________________________________________________________________________
  1.  ;; 
  1.  ;; 5. ROM measurements after repetitive use testing
  1.  ;;
  1.  ;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
  1.  ;; ___ Yes   ___ No    If unable, provide reason: _____________________________
  1.  ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
  1.  ;; If Veteran is able to perform repetitive-use testing, measure and report ROM
  1.  ;; after a minimum of 3 repetitions.
  1.  ;;
  1.  ;; b. Right shoulder post-test ROM
  1.  ;; Select where flexion ends:
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90
  1.  ;; __95   __100  __105  __110  __115  __120  __125  __130  __135
  1.  ;; __140  __145  __150  __155  __160  __165  __170  __175  __180
  1.  ;;
  1.  ;; Select where abduction ends:
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90
  1.  ;; __95   __100  __105  __110  __115  __120  __125  __130  __135
  1.  ;; __140  __145  __150  __155  __160  __165  __170  __175  __180
  1.  ;;^TOF^
  1.  ;; c. Left shoulder post-test ROM
  1.  ;; Select where flexion ends:
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90
  1.  ;; __95   __100  __105  __110  __115  __120  __125  __130  __135
  1.  ;; __140  __145  __150  __155  __160  __165  __170  __175  __180
  1.  ;;
  1.  ;; Select where abduction ends:
  1.  ;; __0    __5    __10   __15   __20   __25   __30   __35   __40   __45
  1.  ;; __50   __55   __60   __65   __70   __75   __80   __85   __90
  1.  ;; __95   __100  __105  __110  __115  __120  __125  __130  __135
  1.  ;; __140  __145  __150  __155  __160  __165  __170  __175  __180
  1.  ;;
  1.  ;; 6. Functional loss and additional limitation in ROM
  1.  ;;
  1.  ;; The following section addresses reasons for functional loss, if present, and
  1.  ;; additional loss of ROM after repetitive-use testing, if present. The VA
  1.  ;; defines functional loss as the inability to perform normal working movements
  1.  ;; of the body with normal excursion, strength, speed, coordination and/or
  1.  ;; endurance.
  1.  ;;
  1.  ;; a. Does the Veteran have additional limitation in ROM of the shoulder and
  1.  ;; arm following repetitive-use testing?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; b. Does the Veteran have any functional loss and/or functional impairment of
  1.  ;; the shoulder and arm?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; c. If the Veteran has functional loss, functional impairment and/or
  1.  ;; additional limitation of ROM of the shoulder and arm after repetitive use,
  1.  ;; indicate the contributing factors of disability below (check all that apply
  1.  ;; and indicate side affected):
  1.  ;;   ___ No functional loss for right upper extremity
  1.  ;;   ___ No functional loss for left upper extremity
  1.  ;;   ___ Less movement than normal              ___ Right   ___ Left   ___ Both
  1.  ;;   ___ More movement than normal              ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Weakened movement                      ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Excess fatigability                    ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Incoordination, impaired ability       ___ Right   ___ Left   ___ Both
  1.  ;;       to execute skilled movements smoothly
  1.  ;;   ___ Pain on movement                       ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Swelling                               ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Deformity                              ___ Right   ___ Left   ___ Both
  1.  ;;   ___ Atrophy of disuse                      ___ Right   ___ Left   ___ Both  
  1.  ;;^TOF^
  1.  ;; 7. Pain (pain on palpation)
  1.  ;;
  1.  ;; a. Does the Veteran have localized tenderness or pain on palpation of
  1.  ;; joints/soft tissue/biceps tendon of either shoulder?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, shoulder affected:   ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Does the Veteran have guarding of either shoulder?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, shoulder affected:   ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; 8. Muscle strength testing
  1.  ;;
  1.  ;; Rate strength according to the following scale:
  1.  ;;    0/5 No muscle movement
  1.  ;;    1/5 Palpable or visible muscle contraction, but no joint movement
  1.  ;;    2/5 Active movement with gravity eliminated
  1.  ;;    3/5 Active movement against gravity
  1.  ;;    4/5 Active movement against some resistance
  1.  ;;    5/5 Normal strength
  1.  ;; Shoulder abduction:
  1.  ;;      Right:  ___ 5/5  ___ 4/5  ___ 3/5  ___ 2/5  ___ 1/5  ___ 0/5
  1.  ;;      Left:   ___ 5/5  ___ 4/5  ___ 3/5  ___ 2/5  ___ 1/5  ___ 0/5
  1.  ;; Shoulder forward flexion:
  1.  ;;      Right:  ___ 5/5  ___ 4/5  ___ 3/5  ___ 2/5  ___ 1/5  ___ 0/5
  1.  ;;      Left:   ___ 5/5  ___ 4/5  ___ 3/5  ___ 2/5  ___ 1/5  ___ 0/5
  1.  ;;
  1.  ;; 9. Ankylosis
  1.  ;;
  1.  ;; Does the Veteran have ankylosis of the glenohumeral articulation (shoulder
  1.  ;; joint)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate severity and side affected:
  1.  ;;    ___ Abduction to 60 degrees; can reach mouth and head
  1.  ;;           ___ Right  ___ Left   ___ Both
  1.  ;;    ___ Abduction limited to between 60 and 25 degrees
  1.  ;;           ___ Right  ___ Left   ___ Both
  1.  ;;    ___ Abduction limited to 25 degrees from the side
  1.  ;;           ___ Right  ___ Left   ___ Both
  1.  ;;
  1.  ;; 10. Specific tests for rotator cuff conditions
  1.  ;;
  1.  ;; a. Hawkins' Impingement Test (Forward flex the arm to 90 degrees with the
  1.  ;; elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation
  1.  ;; indicates a positive test; may signify rotator cuff tendinopathy or tear.)
  1.  ;;    ___ Positive   ___ Negative   ___ Unable to perform   ___ N/A
  1.  ;;    If positive, side affected:   ___ Right   ___ Left    ___ Both
  1.  ;;^TOF^
  1.  ;; b. Empty-can test (Abduct arm to 90 degrees and forward flex 30 degrees.
  1.  ;; Patient turns thumbs down and resists downward force applied by the
  1.  ;; examiner. Weakness indicates a positive test; may indicate rotator cuff
  1.  ;; pathology, including supraspinatus tendinopathy or tear.)
  1.  ;;    ___ Positive   ___ Negative   ___ Unable to perform   ___ N/A
  1.  ;;    If positive, side affected:   ___ Right   ___ Left    ___ Both
  1.  ;;
  1.  ;; c. External rotation/Infraspinatus strength test (Patient holds arm at side
  1.  ;; with elbow flexed 90 degrees. Patient externally rotates against resistance.
  1.  ;; Weakness indicates a positive test; may be associated with infraspinatus
  1.  ;; tendinopathy or tear.)
  1.  ;;    ___ Positive   ___ Negative   ___ Unable to perform   ___ N/A
  1.  ;;    If positive, side affected:   ___ Right   ___ Left    ___ Both
  1.  ;;
  1.  ;; d. Lift-off subscapularis test (Patient internally rotates arm behind lower
  1.  ;; back, pushes against examiner's hand. Weakness indicates a positive test;
  1.  ;; may indicate subscapularis tendinopathy or tear.)
  1.  ;;    ___ Positive   ___ Negative   ___ Unable to perform   ___ N/A
  1.  ;;    If positive, side affected:   ___ Right   ___ Left    ___ Both
  1.  ;;
  1.  ;; 11. History and specific tests for instability/dislocation/labral pathology
  1.  ;;
  1.  ;; a. Is there a history of mechanical symptoms (clicking, catching, etc.)?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, side affected: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Is there a history of recurrent dislocation (subluxation) of the
  1.  ;; glenohumeral (scapulohumeral) joint?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate frequency, severity and side affected (check all that
  1.  ;; apply):
  1.  ;;    ___ Infrequent episodes                 ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Frequent episodes                   ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Guarding of movement only at shoulder level
  1.  ;;                                            ___ Right   ___ Left   ___ Both
  1.  ;;    ___ Guarding of all arm movements       ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; c. Crank apprehension and relocation test (With patient supine, abduct
  1.  ;; patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense of
  1.  ;; instability with further external rotation may indicate shoulder
  1.  ;; instability.)
  1.  ;;    ___ Positive   ___ Negative   ___ Unable to perform  ___ N/A
  1.  ;;    If positive, side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  Q