DVBCQSA2 ;;ALB-CIOFO/ECF - SHOULDER AND ARM QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
;
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 now have or has he/she ever had a shoulder and/or arm
;; condition?
;; ___Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to shoulder and/or arm
;; conditions:
;; Diagnosis #1: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; Diagnosis #2: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; Diagnosis #3: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; If there are additional diagnoses that pertain to shoulder and/or arm
;; conditions, list using above format: _______________________________________
;;
;; 2. Medical history
;;
;; a. Describe the history (including onset and course) of the Veteran's
;; shoulder and/or arm condition (brief summary): _____________________________
;;
;; b. Dominant hand:
;; ___ Right ___ Left ___ Ambidextrous
;;
;; 3. Flare-ups
;;
;; Does the Veteran report that flare-ups impact the function of the shoulder
;; and/or arm?
;; ___ Yes ___ No
;; If yes, document the Veteran's description of the impact of flare-ups in his
;; or her own words: __________________________________________________________
;;^TOF^
;; 4. Initial range of motion (ROM) measurements
;;
;; Measure ROM with a goniometer, rounding each measurement to the nearest
;; 5 degrees. During the measurements, document the point at which painful
;; motion begins, evidenced by visible behavior such as facial expression,
;; wincing, etc. Report initial measurements below.
;;
;; Following the initial assessment of ROM, perform repetitive use testing.
;; For VA purposes, repetitive use testing must be included in all joint
;; exams. The VA has determined that 3 repetitions of ROM (at a minimum) can
;; serve as a representative test of the effect of repetitive use. After the
;; initial measurement, reassess ROM after 3 repetitions. Report post-test
;; measurements in section 5.
;;
;; a. Right shoulder flexion
;; Select where flexion ends (normal endpoint is 180 degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90
;; __95 __100 __105 __110 __115 __120 __125 __130 __135
;; __140 __145 __150 __155 __160 __165 __170 __175 __180
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90
;; __95 __100 __105 __110 __115 __120 __125 __130 __135
;; __140 __145 __150 __155 __160 __165 __170 __175 __180
;;
;; b. Right shoulder abduction
;; Select where abduction ends (normal endpoint is 180 degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90
;; __95 __100 __105 __110 __115 __120 __125 __130 __135
;; __140 __145 __150 __155 __160 __165 __170 __175 __180
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90
;; __95 __100 __105 __110 __115 __120 __125 __130 __135
;; __140 __145 __150 __155 __160 __165 __170 __175 __180
;;
;; c. Left shoulder flexion
;; Select where flexion ends (normal endpoint is 180 degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90
;; __95 __100 __105 __110 __115 __120 __125 __130 __135
;; __140 __145 __150 __155 __160 __165 __170 __175 __180
;;^TOF^
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90
;; __95 __100 __105 __110 __115 __120 __125 __130 __135
;; __140 __145 __150 __155 __160 __165 __170 __175 __180
;;
;; d. Left shoulder abduction
;; Select where abduction ends (normal endpoint is 180 degrees):
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90
;; __95 __100 __105 __110 __115 __120 __125 __130 __135
;; __140 __145 __150 __155 __160 __165 __170 __175 __180
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90
;; __95 __100 __105 __110 __115 __120 __125 __130 __135
;; __140 __145 __150 __155 __160 __165 __170 __175 __180
;;
;; e. If ROM does not conform to the normal range of motion identified above
;; but is normal for this Veteran (for reasons other than a shoulder or arm
;; condition, such as age, body habitus, neurologic disease), explain:
;; ____________________________________________________________________________
;;
;; 5. ROM measurements after repetitive use testing
;;
;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
;; ___ Yes ___ No If unable, provide reason: _____________________________
;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
;; If Veteran is able to perform repetitive-use testing, measure and report ROM
;; after a minimum of 3 repetitions.
;;
;; b. Right shoulder post-test ROM
;; Select where flexion ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90
;; __95 __100 __105 __110 __115 __120 __125 __130 __135
;; __140 __145 __150 __155 __160 __165 __170 __175 __180
;;
;; Select where abduction ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90
;; __95 __100 __105 __110 __115 __120 __125 __130 __135
;; __140 __145 __150 __155 __160 __165 __170 __175 __180
;;^TOF^
;; c. Left shoulder post-test ROM
;; Select where flexion ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90
;; __95 __100 __105 __110 __115 __120 __125 __130 __135
;; __140 __145 __150 __155 __160 __165 __170 __175 __180
;;
;; Select where abduction ends:
;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
;; __50 __55 __60 __65 __70 __75 __80 __85 __90
;; __95 __100 __105 __110 __115 __120 __125 __130 __135
;; __140 __145 __150 __155 __160 __165 __170 __175 __180
;;
;; 6. Functional loss and additional limitation in ROM
;;
;; The following section addresses reasons for functional loss, if present, and
;; additional loss of ROM after repetitive-use testing, if present. The VA
;; defines functional loss as the inability to perform normal working movements
;; of the body with normal excursion, strength, speed, coordination and/or
;; endurance.
;;
;; a. Does the Veteran have additional limitation in ROM of the shoulder and
;; arm following repetitive-use testing?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have any functional loss and/or functional impairment of
;; the shoulder and arm?
;; ___ Yes ___ No
;;
;; c. If the Veteran has functional loss, functional impairment and/or
;; additional limitation of ROM of the shoulder and arm after repetitive use,
;; indicate the contributing factors of disability below (check all that apply
;; and indicate side affected):
;; ___ No functional loss for right upper extremity
;; ___ No functional loss for left upper extremity
;; ___ Less movement than normal ___ Right ___ Left ___ Both
;; ___ More movement than normal ___ Right ___ Left ___ Both
;; ___ Weakened movement ___ Right ___ Left ___ Both
;; ___ Excess fatigability ___ Right ___ Left ___ Both
;; ___ Incoordination, impaired ability ___ Right ___ Left ___ Both
;; to execute skilled movements smoothly
;; ___ Pain on movement ___ Right ___ Left ___ Both
;; ___ Swelling ___ Right ___ Left ___ Both
;; ___ Deformity ___ Right ___ Left ___ Both
;; ___ Atrophy of disuse ___ Right ___ Left ___ Both
;;^TOF^
;; 7. Pain (pain on palpation)
;;
;; a. Does the Veteran have localized tenderness or pain on palpation of
;; joints/soft tissue/biceps tendon of either shoulder?
;; ___ Yes ___ No
;; If yes, shoulder affected: ___ Right ___ Left ___ Both
;;
;; b. Does the Veteran have guarding of either shoulder?
;; ___ Yes ___ No
;; If yes, shoulder affected: ___ Right ___ Left ___ Both
;;
;; 8. Muscle strength testing
;;
;; 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
;; Shoulder abduction:
;; 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
;; Shoulder forward 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
;;
;; 9. Ankylosis
;;
;; Does the Veteran have ankylosis of the glenohumeral articulation (shoulder
;; joint)?
;; ___ Yes ___ No
;; If yes, indicate severity and side affected:
;; ___ Abduction to 60 degrees; can reach mouth and head
;; ___ Right ___ Left ___ Both
;; ___ Abduction limited to between 60 and 25 degrees
;; ___ Right ___ Left ___ Both
;; ___ Abduction limited to 25 degrees from the side
;; ___ Right ___ Left ___ Both
;;
;; 10. Specific tests for rotator cuff conditions
;;
;; a. Hawkins' Impingement Test (Forward flex the arm to 90 degrees with the
;; elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation
;; indicates a positive test; may signify rotator cuff tendinopathy or tear.)
;; ___ Positive ___ Negative ___ Unable to perform ___ N/A
;; If positive, side affected: ___ Right ___ Left ___ Both
;;^TOF^
;; b. Empty-can test (Abduct arm to 90 degrees and forward flex 30 degrees.
;; Patient turns thumbs down and resists downward force applied by the
;; examiner. Weakness indicates a positive test; may indicate rotator cuff
;; pathology, including supraspinatus tendinopathy or tear.)
;; ___ Positive ___ Negative ___ Unable to perform ___ N/A
;; If positive, side affected: ___ Right ___ Left ___ Both
;;
;; c. External rotation/Infraspinatus strength test (Patient holds arm at side
;; with elbow flexed 90 degrees. Patient externally rotates against resistance.
;; Weakness indicates a positive test; may be associated with infraspinatus
;; tendinopathy or tear.)
;; ___ Positive ___ Negative ___ Unable to perform ___ N/A
;; If positive, side affected: ___ Right ___ Left ___ Both
;;
;; d. Lift-off subscapularis test (Patient internally rotates arm behind lower
;; back, pushes against examiner's hand. Weakness indicates a positive test;
;; may indicate subscapularis tendinopathy or tear.)
;; ___ Positive ___ Negative ___ Unable to perform ___ N/A
;; If positive, side affected: ___ Right ___ Left ___ Both
;;
;; 11. History and specific tests for instability/dislocation/labral pathology
;;
;; a. Is there a history of mechanical symptoms (clicking, catching, etc.)?
;; ___ Yes ___ No
;; If yes, side affected: ___ Right ___ Left ___ Both
;;
;; b. Is there a history of recurrent dislocation (subluxation) of the
;; glenohumeral (scapulohumeral) joint?
;; ___ Yes ___ No
;; If yes, indicate frequency, severity and side affected (check all that
;; apply):
;; ___ Infrequent episodes ___ Right ___ Left ___ Both
;; ___ Frequent episodes ___ Right ___ Left ___ Both
;; ___ Guarding of movement only at shoulder level
;; ___ Right ___ Left ___ Both
;; ___ Guarding of all arm movements ___ Right ___ Left ___ Both
;;
;; c. Crank apprehension and relocation test (With patient supine, abduct
;; patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense of
;; instability with further external rotation may indicate shoulder
;; instability.)
;; ___ Positive ___ Negative ___ Unable to perform ___ N/A
;; If positive, side affected: ___ Right ___ Left ___ Both
;;
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQSA2 14201 printed Dec 13, 2024@01:48:03 Page 2
DVBCQSA2 ;;ALB-CIOFO/ECF - SHOULDER AND ARM QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;;
+2 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA)
+3 ;; for disability benefits. VA will consider the information you provide on
+4 ;; this questionnaire as part of their evaluation in processing the Veteran's
+5 ;; claim.
+6 ;;
+7 ;; 1. Diagnosis
+8 ;;
+9 ;; Does the Veteran now have or has he/she ever had a shoulder and/or arm
+10 ;; condition?
+11 ;; ___Yes ___ No
+12 ;;
+13 ;; If yes, provide only diagnoses that pertain to shoulder and/or arm
+14 ;; conditions:
+15 ;; Diagnosis #1: ___________________
+16 ;; ICD code: ______________________
+17 ;; Date of diagnosis: ______________
+18 ;; Side affected: ___ Right ___ Left ___ Both
+19 ;;
+20 ;; Diagnosis #2: ___________________
+21 ;; ICD code: ______________________
+22 ;; Date of diagnosis: ______________
+23 ;; Side affected: ___ Right ___ Left ___ Both
+24 ;;
+25 ;; Diagnosis #3: ___________________
+26 ;; ICD code: ______________________
+27 ;; Date of diagnosis: ______________
+28 ;; Side affected: ___ Right ___ Left ___ Both
+29 ;;
+30 ;; If there are additional diagnoses that pertain to shoulder and/or arm
+31 ;; conditions, list using above format: _______________________________________
+32 ;;
+33 ;; 2. Medical history
+34 ;;
+35 ;; a. Describe the history (including onset and course) of the Veteran's
+36 ;; shoulder and/or arm condition (brief summary): _____________________________
+37 ;;
+38 ;; b. Dominant hand:
+39 ;; ___ Right ___ Left ___ Ambidextrous
+40 ;;
+41 ;; 3. Flare-ups
+42 ;;
+43 ;; Does the Veteran report that flare-ups impact the function of the shoulder
+44 ;; and/or arm?
+45 ;; ___ Yes ___ No
+46 ;; If yes, document the Veteran's description of the impact of flare-ups in his
+47 ;; or her own words: __________________________________________________________
+48 ;;^TOF^
+49 ;; 4. Initial range of motion (ROM) measurements
+50 ;;
+51 ;; Measure ROM with a goniometer, rounding each measurement to the nearest
+52 ;; 5 degrees. During the measurements, document the point at which painful
+53 ;; motion begins, evidenced by visible behavior such as facial expression,
+54 ;; wincing, etc. Report initial measurements below.
+55 ;;
+56 ;; Following the initial assessment of ROM, perform repetitive use testing.
+57 ;; For VA purposes, repetitive use testing must be included in all joint
+58 ;; exams. The VA has determined that 3 repetitions of ROM (at a minimum) can
+59 ;; serve as a representative test of the effect of repetitive use. After the
+60 ;; initial measurement, reassess ROM after 3 repetitions. Report post-test
+61 ;; measurements in section 5.
+62 ;;
+63 ;; a. Right shoulder flexion
+64 ;; Select where flexion ends (normal endpoint is 180 degrees):
+65 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+66 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90
+67 ;; __95 __100 __105 __110 __115 __120 __125 __130 __135
+68 ;; __140 __145 __150 __155 __160 __165 __170 __175 __180
+69 ;;
+70 ;; Select where objective evidence of painful motion begins:
+71 ;; ___ No objective evidence of painful motion
+72 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+73 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90
+74 ;; __95 __100 __105 __110 __115 __120 __125 __130 __135
+75 ;; __140 __145 __150 __155 __160 __165 __170 __175 __180
+76 ;;
+77 ;; b. Right shoulder abduction
+78 ;; Select where abduction ends (normal endpoint is 180 degrees):
+79 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+80 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90
+81 ;; __95 __100 __105 __110 __115 __120 __125 __130 __135
+82 ;; __140 __145 __150 __155 __160 __165 __170 __175 __180
+83 ;;
+84 ;; Select where objective evidence of painful motion begins:
+85 ;; ___ No objective evidence of painful motion
+86 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+87 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90
+88 ;; __95 __100 __105 __110 __115 __120 __125 __130 __135
+89 ;; __140 __145 __150 __155 __160 __165 __170 __175 __180
+90 ;;
+91 ;; c. Left shoulder flexion
+92 ;; Select where flexion ends (normal endpoint is 180 degrees):
+93 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+94 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90
+95 ;; __95 __100 __105 __110 __115 __120 __125 __130 __135
+96 ;; __140 __145 __150 __155 __160 __165 __170 __175 __180
+97 ;;^TOF^
+98 ;; Select where objective evidence of painful motion begins:
+99 ;; ___ No objective evidence of painful motion
+100 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+101 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90
+102 ;; __95 __100 __105 __110 __115 __120 __125 __130 __135
+103 ;; __140 __145 __150 __155 __160 __165 __170 __175 __180
+104 ;;
+105 ;; d. Left shoulder abduction
+106 ;; Select where abduction ends (normal endpoint is 180 degrees):
+107 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+108 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90
+109 ;; __95 __100 __105 __110 __115 __120 __125 __130 __135
+110 ;; __140 __145 __150 __155 __160 __165 __170 __175 __180
+111 ;;
+112 ;; Select where objective evidence of painful motion begins:
+113 ;; ___ No objective evidence of painful motion
+114 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+115 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90
+116 ;; __95 __100 __105 __110 __115 __120 __125 __130 __135
+117 ;; __140 __145 __150 __155 __160 __165 __170 __175 __180
+118 ;;
+119 ;; e. If ROM does not conform to the normal range of motion identified above
+120 ;; but is normal for this Veteran (for reasons other than a shoulder or arm
+121 ;; condition, such as age, body habitus, neurologic disease), explain:
+122 ;; ____________________________________________________________________________
+123 ;;
+124 ;; 5. ROM measurements after repetitive use testing
+125 ;;
+126 ;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
+127 ;; ___ Yes ___ No If unable, provide reason: _____________________________
+128 ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
+129 ;; If Veteran is able to perform repetitive-use testing, measure and report ROM
+130 ;; after a minimum of 3 repetitions.
+131 ;;
+132 ;; b. Right shoulder post-test ROM
+133 ;; Select where flexion ends:
+134 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+135 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90
+136 ;; __95 __100 __105 __110 __115 __120 __125 __130 __135
+137 ;; __140 __145 __150 __155 __160 __165 __170 __175 __180
+138 ;;
+139 ;; Select where abduction ends:
+140 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+141 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90
+142 ;; __95 __100 __105 __110 __115 __120 __125 __130 __135
+143 ;; __140 __145 __150 __155 __160 __165 __170 __175 __180
+144 ;;^TOF^
+145 ;; c. Left shoulder post-test ROM
+146 ;; Select where flexion ends:
+147 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+148 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90
+149 ;; __95 __100 __105 __110 __115 __120 __125 __130 __135
+150 ;; __140 __145 __150 __155 __160 __165 __170 __175 __180
+151 ;;
+152 ;; Select where abduction ends:
+153 ;; __0 __5 __10 __15 __20 __25 __30 __35 __40 __45
+154 ;; __50 __55 __60 __65 __70 __75 __80 __85 __90
+155 ;; __95 __100 __105 __110 __115 __120 __125 __130 __135
+156 ;; __140 __145 __150 __155 __160 __165 __170 __175 __180
+157 ;;
+158 ;; 6. Functional loss and additional limitation in ROM
+159 ;;
+160 ;; The following section addresses reasons for functional loss, if present, and
+161 ;; additional loss of ROM after repetitive-use testing, if present. The VA
+162 ;; defines functional loss as the inability to perform normal working movements
+163 ;; of the body with normal excursion, strength, speed, coordination and/or
+164 ;; endurance.
+165 ;;
+166 ;; a. Does the Veteran have additional limitation in ROM of the shoulder and
+167 ;; arm following repetitive-use testing?
+168 ;; ___ Yes ___ No
+169 ;;
+170 ;; b. Does the Veteran have any functional loss and/or functional impairment of
+171 ;; the shoulder and arm?
+172 ;; ___ Yes ___ No
+173 ;;
+174 ;; c. If the Veteran has functional loss, functional impairment and/or
+175 ;; additional limitation of ROM of the shoulder and arm after repetitive use,
+176 ;; indicate the contributing factors of disability below (check all that apply
+177 ;; and indicate side affected):
+178 ;; ___ No functional loss for right upper extremity
+179 ;; ___ No functional loss for left upper extremity
+180 ;; ___ Less movement than normal ___ Right ___ Left ___ Both
+181 ;; ___ More movement than normal ___ Right ___ Left ___ Both
+182 ;; ___ Weakened movement ___ Right ___ Left ___ Both
+183 ;; ___ Excess fatigability ___ Right ___ Left ___ Both
+184 ;; ___ Incoordination, impaired ability ___ Right ___ Left ___ Both
+185 ;; to execute skilled movements smoothly
+186 ;; ___ Pain on movement ___ Right ___ Left ___ Both
+187 ;; ___ Swelling ___ Right ___ Left ___ Both
+188 ;; ___ Deformity ___ Right ___ Left ___ Both
+189 ;; ___ Atrophy of disuse ___ Right ___ Left ___ Both
+190 ;;^TOF^
+191 ;; 7. Pain (pain on palpation)
+192 ;;
+193 ;; a. Does the Veteran have localized tenderness or pain on palpation of
+194 ;; joints/soft tissue/biceps tendon of either shoulder?
+195 ;; ___ Yes ___ No
+196 ;; If yes, shoulder affected: ___ Right ___ Left ___ Both
+197 ;;
+198 ;; b. Does the Veteran have guarding of either shoulder?
+199 ;; ___ Yes ___ No
+200 ;; If yes, shoulder affected: ___ Right ___ Left ___ Both
+201 ;;
+202 ;; 8. Muscle strength testing
+203 ;;
+204 ;; Rate strength according to the following scale:
+205 ;; 0/5 No muscle movement
+206 ;; 1/5 Palpable or visible muscle contraction, but no joint movement
+207 ;; 2/5 Active movement with gravity eliminated
+208 ;; 3/5 Active movement against gravity
+209 ;; 4/5 Active movement against some resistance
+210 ;; 5/5 Normal strength
+211 ;; Shoulder abduction:
+212 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+213 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+214 ;; Shoulder forward flexion:
+215 ;; Right: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+216 ;; Left: ___ 5/5 ___ 4/5 ___ 3/5 ___ 2/5 ___ 1/5 ___ 0/5
+217 ;;
+218 ;; 9. Ankylosis
+219 ;;
+220 ;; Does the Veteran have ankylosis of the glenohumeral articulation (shoulder
+221 ;; joint)?
+222 ;; ___ Yes ___ No
+223 ;; If yes, indicate severity and side affected:
+224 ;; ___ Abduction to 60 degrees; can reach mouth and head
+225 ;; ___ Right ___ Left ___ Both
+226 ;; ___ Abduction limited to between 60 and 25 degrees
+227 ;; ___ Right ___ Left ___ Both
+228 ;; ___ Abduction limited to 25 degrees from the side
+229 ;; ___ Right ___ Left ___ Both
+230 ;;
+231 ;; 10. Specific tests for rotator cuff conditions
+232 ;;
+233 ;; a. Hawkins' Impingement Test (Forward flex the arm to 90 degrees with the
+234 ;; elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation
+235 ;; indicates a positive test; may signify rotator cuff tendinopathy or tear.)
+236 ;; ___ Positive ___ Negative ___ Unable to perform ___ N/A
+237 ;; If positive, side affected: ___ Right ___ Left ___ Both
+238 ;;^TOF^
+239 ;; b. Empty-can test (Abduct arm to 90 degrees and forward flex 30 degrees.
+240 ;; Patient turns thumbs down and resists downward force applied by the
+241 ;; examiner. Weakness indicates a positive test; may indicate rotator cuff
+242 ;; pathology, including supraspinatus tendinopathy or tear.)
+243 ;; ___ Positive ___ Negative ___ Unable to perform ___ N/A
+244 ;; If positive, side affected: ___ Right ___ Left ___ Both
+245 ;;
+246 ;; c. External rotation/Infraspinatus strength test (Patient holds arm at side
+247 ;; with elbow flexed 90 degrees. Patient externally rotates against resistance.
+248 ;; Weakness indicates a positive test; may be associated with infraspinatus
+249 ;; tendinopathy or tear.)
+250 ;; ___ Positive ___ Negative ___ Unable to perform ___ N/A
+251 ;; If positive, side affected: ___ Right ___ Left ___ Both
+252 ;;
+253 ;; d. Lift-off subscapularis test (Patient internally rotates arm behind lower
+254 ;; back, pushes against examiner's hand. Weakness indicates a positive test;
+255 ;; may indicate subscapularis tendinopathy or tear.)
+256 ;; ___ Positive ___ Negative ___ Unable to perform ___ N/A
+257 ;; If positive, side affected: ___ Right ___ Left ___ Both
+258 ;;
+259 ;; 11. History and specific tests for instability/dislocation/labral pathology
+260 ;;
+261 ;; a. Is there a history of mechanical symptoms (clicking, catching, etc.)?
+262 ;; ___ Yes ___ No
+263 ;; If yes, side affected: ___ Right ___ Left ___ Both
+264 ;;
+265 ;; b. Is there a history of recurrent dislocation (subluxation) of the
+266 ;; glenohumeral (scapulohumeral) joint?
+267 ;; ___ Yes ___ No
+268 ;; If yes, indicate frequency, severity and side affected (check all that
+269 ;; apply):
+270 ;; ___ Infrequent episodes ___ Right ___ Left ___ Both
+271 ;; ___ Frequent episodes ___ Right ___ Left ___ Both
+272 ;; ___ Guarding of movement only at shoulder level
+273 ;; ___ Right ___ Left ___ Both
+274 ;; ___ Guarding of all arm movements ___ Right ___ Left ___ Both
+275 ;;
+276 ;; c. Crank apprehension and relocation test (With patient supine, abduct
+277 ;; patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense of
+278 ;; instability with further external rotation may indicate shoulder
+279 ;; instability.)
+280 ;; ___ Positive ___ Negative ___ Unable to perform ___ N/A
+281 ;; If positive, side affected: ___ Right ___ Left ___ Both
+282 ;;
+283 QUIT
