DVBCQSA3 ;;ALB-CIOFO/ECF - SHOULDER AND ARM QUESTIONNAIRE ; 6/15/2011
;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
;
TXT ;
;;
;;^TOF^
;; 12. History and specific tests for clavicle, scapula, acromioclavicular (AC)
;; joint, and sternoclavicular joint conditions
;;
;; a. Does the Veteran have an AC joint condition or any other impairment of
;; the clavicle or scapula?
;; ___ Yes ___ No
;; If yes, indicate severity and side affected:
;; ___ Malunion of clavicle or scapula ___ Right ___ Left ___ Both
;; ___ Nonunion of clavicle or scapula without loose movement
;; ___ Right ___ Left ___ Both
;; ___ Nonunion of clavicle or scapula with loose movement
;; ___ Right ___ Left ___ Both
;; ___ Dislocation (acromioclavicular separation or sternoclavicular
;; dislocation)
;; ___ Right ___ Left ___ Both
;; ___ Other, describe: ____________________________________________________
;; ___ Right ___ Left ___ Both
;;
;; b. Is there tenderness on palpation of the AC joint?
;; ___ Yes ___ No
;; If yes, indicate side: ___ Right ___ Left ___ Both
;;
;; c. Cross-body adduction test (Passively adduct arm across the patient's body
;; toward the contralateral shoulder. Pain may indicate acromioclavicular joint
;; pathology.)
;; ___ Positive ___ Negative ___ Unable to perform ___ N/A
;; If positive, side affected: ___ Right ___ Left ___ Both
;;
;; 13. Joint replacement and/or other surgical procedures
;;
;; a. Has the Veteran had a total shoulder joint replacement?
;; ___ Yes ___ No
;; If yes, indicate side and severity of residuals.
;; ___ Right shoulder
;; Date of surgery: ___________________
;; Residuals:
;; ___ None
;; ___ Intermediate degrees of residual weakness, pain and/or limitation
;; of motion
;; ___ Chronic residuals consisting of severe painful motion and/or
;; weakness
;; ___ Other, describe: _________________________________________________
;;^TOF^
;; ___ Left shoulder
;; Date of surgery: ___________________
;; Residuals:
;; ___ None
;; ___ Intermediate degrees of residual weakness, pain and/or limitation
;; of motion
;; ___ Chronic residuals consisting of severe painful motion and/or
;; weakness
;; ___ Other, describe: _________________________________________________
;;
;; b. Has the Veteran had arthroscopic or other shoulder surgery?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; Date and type of surgery: _______________________________________________
;;
;; c. Does the Veteran have any residual signs and/or symptoms due to
;; arthroscopic or other shoulder surgery?
;; ___Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; If yes, describe residuals: _____________________________________________
;;
;; 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 and/or symptoms related to any conditions
;; listed in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): _________________________________________
;;
;; 15. Remaining effective function of the extremities
;;
;; Due to the Veteran shoulder and/or arm 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)
;; ___Yes, functioning is so diminished that amputation with prosthesis would
;; equally serve the Veteran.
;; ___ No
;;^TOF^
;; If yes, indicate extremity(ies) (check all extremities for which this
;; applies):
;; ___ Right upper ___ Left upper
;; For each checked extremity, describe loss of effective function, identify
;; the condition causing loss of function, and provide specific examples
;; (brief summary): ___________________________________________________________
;;
;; 16. Diagnostic Testing
;;
;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
;; arthritis must be confirmed by imaging studies. Once such arthritis has been
;; documented, no further imaging studies are required by VA, even if arthritis
;; has worsened.
;;
;; a. Have imaging studies of the shoulder been performed and are the results
;; available?
;; ___ Yes ___ No
;; If yes, is degenerative or traumatic arthritis documented?
;; ___ Yes ___ No
;; If yes, indicate shoulder: ___ Right ___ Left ___ Both
;;
;; 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): __________________________________________________________________
;;
;; 17. Functional impact
;;
;; Does the Veteran's shoulder condition impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's shoulder conditions
;; providing one or more examples: ____________________________________________
;;
;; 18. 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[HDVBCQSA3 6815 printed Nov 22, 2024@16:58:16 Page 2
DVBCQSA3 ;;ALB-CIOFO/ECF - SHOULDER AND ARM QUESTIONNAIRE ; 6/15/2011
+1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
+2 ;
TXT ;
+1 ;;
+2 ;;^TOF^
+3 ;; 12. History and specific tests for clavicle, scapula, acromioclavicular (AC)
+4 ;; joint, and sternoclavicular joint conditions
+5 ;;
+6 ;; a. Does the Veteran have an AC joint condition or any other impairment of
+7 ;; the clavicle or scapula?
+8 ;; ___ Yes ___ No
+9 ;; If yes, indicate severity and side affected:
+10 ;; ___ Malunion of clavicle or scapula ___ Right ___ Left ___ Both
+11 ;; ___ Nonunion of clavicle or scapula without loose movement
+12 ;; ___ Right ___ Left ___ Both
+13 ;; ___ Nonunion of clavicle or scapula with loose movement
+14 ;; ___ Right ___ Left ___ Both
+15 ;; ___ Dislocation (acromioclavicular separation or sternoclavicular
+16 ;; dislocation)
+17 ;; ___ Right ___ Left ___ Both
+18 ;; ___ Other, describe: ____________________________________________________
+19 ;; ___ Right ___ Left ___ Both
+20 ;;
+21 ;; b. Is there tenderness on palpation of the AC joint?
+22 ;; ___ Yes ___ No
+23 ;; If yes, indicate side: ___ Right ___ Left ___ Both
+24 ;;
+25 ;; c. Cross-body adduction test (Passively adduct arm across the patient's body
+26 ;; toward the contralateral shoulder. Pain may indicate acromioclavicular joint
+27 ;; pathology.)
+28 ;; ___ Positive ___ Negative ___ Unable to perform ___ N/A
+29 ;; If positive, side affected: ___ Right ___ Left ___ Both
+30 ;;
+31 ;; 13. Joint replacement and/or other surgical procedures
+32 ;;
+33 ;; a. Has the Veteran had a total shoulder joint replacement?
+34 ;; ___ Yes ___ No
+35 ;; If yes, indicate side and severity of residuals.
+36 ;; ___ Right shoulder
+37 ;; Date of surgery: ___________________
+38 ;; Residuals:
+39 ;; ___ None
+40 ;; ___ Intermediate degrees of residual weakness, pain and/or limitation
+41 ;; of motion
+42 ;; ___ Chronic residuals consisting of severe painful motion and/or
+43 ;; weakness
+44 ;; ___ Other, describe: _________________________________________________
+45 ;;^TOF^
+46 ;; ___ Left shoulder
+47 ;; Date of surgery: ___________________
+48 ;; Residuals:
+49 ;; ___ None
+50 ;; ___ Intermediate degrees of residual weakness, pain and/or limitation
+51 ;; of motion
+52 ;; ___ Chronic residuals consisting of severe painful motion and/or
+53 ;; weakness
+54 ;; ___ Other, describe: _________________________________________________
+55 ;;
+56 ;; b. Has the Veteran had arthroscopic or other shoulder surgery?
+57 ;; ___ Yes ___ No
+58 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+59 ;; Date and type of surgery: _______________________________________________
+60 ;;
+61 ;; c. Does the Veteran have any residual signs and/or symptoms due to
+62 ;; arthroscopic or other shoulder surgery?
+63 ;; ___Yes ___ No
+64 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+65 ;; If yes, describe residuals: _____________________________________________
+66 ;;
+67 ;; 14. Other pertinent physical findings, complications, conditions, signs
+68 ;; and/or symptoms
+69 ;;
+70 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+71 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+72 ;; section above?
+73 ;; ___ Yes ___ No
+74 ;; If yes, are any of the scars painful and/or unstable, or is the total
+75 ;; area of all related scars greater than 39 square cm (6 square inches)?
+76 ;; ___ Yes ___ No
+77 ;; If yes, also complete a Scars Questionnaire.
+78 ;;
+79 ;; b. Does the Veteran have any other pertinent physical findings,
+80 ;; complications, conditions, signs and/or symptoms related to any conditions
+81 ;; listed in the Diagnosis section above?
+82 ;; ___ Yes ___ No
+83 ;; If yes, describe (brief summary): _________________________________________
+84 ;;
+85 ;; 15. Remaining effective function of the extremities
+86 ;;
+87 ;; Due to the Veteran shoulder and/or arm conditions, is there functional
+88 ;; impairment of an extremity such that no effective function remains other
+89 ;; than that which would be equally well served by an amputation with
+90 ;; prosthesis? (Functions of the upper extremity include grasping,
+91 ;; manipulation, etc)
+92 ;; ___Yes, functioning is so diminished that amputation with prosthesis would
+93 ;; equally serve the Veteran.
+94 ;; ___ No
+95 ;;^TOF^
+96 ;; If yes, indicate extremity(ies) (check all extremities for which this
+97 ;; applies):
+98 ;; ___ Right upper ___ Left upper
+99 ;; For each checked extremity, describe loss of effective function, identify
+100 ;; the condition causing loss of function, and provide specific examples
+101 ;; (brief summary): ___________________________________________________________
+102 ;;
+103 ;; 16. Diagnostic Testing
+104 ;;
+105 ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic
+106 ;; arthritis must be confirmed by imaging studies. Once such arthritis has been
+107 ;; documented, no further imaging studies are required by VA, even if arthritis
+108 ;; has worsened.
+109 ;;
+110 ;; a. Have imaging studies of the shoulder been performed and are the results
+111 ;; available?
+112 ;; ___ Yes ___ No
+113 ;; If yes, is degenerative or traumatic arthritis documented?
+114 ;; ___ Yes ___ No
+115 ;; If yes, indicate shoulder: ___ Right ___ Left ___ Both
+116 ;;
+117 ;; b. Are there any other significant diagnostic test findings and/or results?
+118 ;; ___ Yes ___ No
+119 ;; If yes, provide type of test or procedure, date and results (brief
+120 ;; summary): __________________________________________________________________
+121 ;;
+122 ;; 17. Functional impact
+123 ;;
+124 ;; Does the Veteran's shoulder condition impact his or her ability to work?
+125 ;; ___ Yes ___ No
+126 ;; If yes, describe the impact of each of the Veteran's shoulder conditions
+127 ;; providing one or more examples: ____________________________________________
+128 ;;
+129 ;; 18. Remarks, if any: _______________________________________________________
+130 ;;
+131 ;; Physician signature: ____________________________________ Date: ____________
+132 ;;
+133 ;; Physician printed name: ____________________________________________________
+134 ;;
+135 ;; Medical license #: _________________________________________________________
+136 ;;
+137 ;; Physician address: _________________________________________________________
+138 ;;
+139 ;; Phone: ____________________________ FAX: _______________________________
+140 ;;
+141 ;; NOTE: VA may request additional medical information, including additional
+142 ;; examinations if necessary to complete VA's review of the Veteran's
+143 ;; application.
+144 ;;
+145 ;;^END^
+146 ;;
+147 QUIT
