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Routine: DVBCQSA3

DVBCQSA3.m

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  1. DVBCQSA3 ;;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.  ;;^TOF^
  1.  ;; 12. History and specific tests for clavicle, scapula, acromioclavicular (AC)
  1.  ;; joint, and sternoclavicular joint conditions
  1.  ;;
  1.  ;; a. Does the Veteran have an AC joint condition or any other impairment of
  1.  ;; the clavicle or scapula?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate severity and side affected:
  1.  ;;    ___ Malunion of clavicle or scapula       ___ Right  ___ Left   ___ Both
  1.  ;;    ___ Nonunion of clavicle or scapula without loose movement
  1.  ;;                                              ___ Right  ___ Left   ___ Both
  1.  ;;    ___ Nonunion of clavicle or scapula with loose movement
  1.  ;;                                              ___ Right  ___ Left   ___ Both
  1.  ;;    ___ Dislocation (acromioclavicular separation or sternoclavicular
  1.  ;;       dislocation)
  1.  ;;                                              ___ Right  ___ Left   ___ Both
  1.  ;;    ___ Other, describe: ____________________________________________________
  1.  ;;                                              ___ Right  ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Is there tenderness on palpation of the AC joint?
  1.  ;; ___ Yes   ___ No
  1.  ;;    If yes, indicate side: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; c. Cross-body adduction test (Passively adduct arm across the patient's body
  1.  ;; toward the contralateral shoulder. Pain may indicate acromioclavicular joint
  1.  ;; pathology.)
  1.  ;;    ___ Positive   ___ Negative   ___ Unable to perform   ___ N/A
  1.  ;;    If positive, side affected:   ___ Right    ___ Left   ___ Both
  1.  ;;
  1.  ;; 13.  Joint replacement and/or other surgical procedures
  1.  ;;
  1.  ;; a. Has the Veteran had a total shoulder joint replacement?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side and severity of residuals.
  1.  ;;   ___ Right shoulder
  1.  ;;       Date of surgery: ___________________
  1.  ;;       Residuals:
  1.  ;;       ___ None
  1.  ;;       ___ Intermediate degrees of residual weakness, pain and/or limitation
  1.  ;;           of motion
  1.  ;;       ___ Chronic residuals consisting of severe painful motion and/or
  1.  ;;           weakness
  1.  ;;       ___ Other, describe: _________________________________________________
  1.  ;;^TOF^
  1.  ;;   ___ Left shoulder
  1.  ;;       Date of surgery: ___________________
  1.  ;;       Residuals:
  1.  ;;       ___ None
  1.  ;;       ___ Intermediate degrees of residual weakness, pain and/or limitation
  1.  ;;           of motion
  1.  ;;       ___ Chronic residuals consisting of severe painful motion and/or
  1.  ;;           weakness
  1.  ;;       ___ Other, describe: _________________________________________________
  1.  ;;
  1.  ;; b. Has the Veteran had arthroscopic or other shoulder surgery?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;    Date and type of surgery: _______________________________________________
  1.  ;;
  1.  ;; c. Does the Veteran have any residual signs and/or symptoms due to
  1.  ;; arthroscopic or other shoulder surgery?
  1.  ;; ___Yes    ___ No
  1.  ;; If yes, indicate side affected:   ___ Right   ___ Left   ___ Both
  1.  ;;    If yes, describe residuals: _____________________________________________
  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
  1.  ;;    area 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 and/or symptoms related to any conditions
  1.  ;; listed in the Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): _________________________________________
  1.  ;;
  1.  ;; 15. Remaining effective function of the extremities
  1.  ;;
  1.  ;; Due to the Veteran shoulder and/or arm conditions, is there functional
  1.  ;; impairment of an extremity such that no effective function remains other
  1.  ;; than that which would be equally well served by an amputation with
  1.  ;; prosthesis? (Functions of the upper extremity include grasping,
  1.  ;; manipulation, etc)
  1.  ;; ___Yes, functioning is so diminished that amputation with prosthesis would
  1.  ;; equally serve the Veteran.
  1.  ;; ___ No
  1.  ;;^TOF^
  1.  ;;    If yes, indicate extremity(ies) (check all extremities for which this
  1.  ;;    applies):
  1.  ;;    ___ Right upper    ___ Left upper
  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.  ;; 16.  Diagnostic Testing
  1.  ;;
  1.  ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
  1.  ;; arthritis must be confirmed by imaging studies. Once such arthritis has been
  1.  ;; documented, no further imaging studies are required by VA, even if arthritis
  1.  ;; has worsened.
  1.  ;;
  1.  ;; a. Have imaging studies of the shoulder been performed and are the results
  1.  ;; available?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, is degenerative or traumatic arthritis documented?
  1.  ;; ___ Yes   ___ No
  1.  ;;    If yes, indicate shoulder: ___ Right   ___ Left   ___ Both
  1.  ;;
  1.  ;; b. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, provide type of test or procedure, date and results (brief
  1.  ;; summary): __________________________________________________________________
  1.  ;;
  1.  ;; 17. Functional impact
  1.  ;;
  1.  ;; Does the Veteran's shoulder condition impact his or her ability to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe the impact of each of the Veteran's shoulder conditions
  1.  ;; providing one or more examples: ____________________________________________
  1.  ;;
  1.  ;; 18. 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.  ;;
  1.  Q