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Routine: DVBCQTJ2

DVBCQTJ2.m

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  1. DVBCQTJ2 ;;ALB-CIOFO/ECF - TEMPOROMANDIBULAR JOINT(TMJ) CONDITIONS QUESTIONNAIRE ; 9/JUNE/2011
  1.  ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
  1.  ;
  1. TXT ;
  1.  ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
  1.  ;; disability benefits.  VA will consider the information you provide on this
  1.  ;; questionnaire as part of their evaluation in processing the Veteran's claim.
  1.  ;;
  1.  ;; 1. Diagnosis
  1.  ;; Does the Veteran now have or has he/she ever had a temporomandibular joint
  1.  ;; condition?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; If yes, provide only diagnoses that pertain to temporomandibular joint
  1.  ;; conditions:
  1.  ;;
  1.  ;; Diagnosis #1: _________________________
  1.  ;; ICD code: _____________________________
  1.  ;; Date of diagnosis: ____________________
  1.  ;;
  1.  ;; Diagnosis #2: _________________________
  1.  ;; ICD code: _____________________________
  1.  ;; Date of diagnosis: ____________________
  1.  ;;
  1.  ;; Diagnosis #3: _________________________
  1.  ;; ICD code: _____________________________
  1.  ;; Date of diagnosis: ____________________
  1.  ;;
  1.  ;; If there are additional diagnoses that pertain to temporomandibular
  1.  ;; joint conditions, list using above format.
  1.  ;;
  1.  ;; 2. Medical History
  1.  ;; a. Describe the history (including onset and course) of the Veteran's
  1.  ;; temporomandibular joint condition (brief summary): __________________________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 3. Flare-ups
  1.  ;; Does the Veteran report that flare-ups impact the function of the
  1.  ;; temporomandibular joint? 
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, document the Veteran's description of the impact of flare-ups on
  1.  ;;
  1.  ;; function in his or her own words: ___________________________________________
  1.  ;;^TOF^
  1.  ;; 4. Initial range of motion (ROM) measurements
  1.  ;; Measure ROM. 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. For
  1.  ;; VA purposes, repetitive use testing must be included in all joint exams. The
  1.  ;; VA has determined that 3 repetitions of ROM (at a minimum) can serve as a
  1.  ;; representative test of the effect of repetitive use. After the initial
  1.  ;; measurement, reassess ROM after 3 repetitions. Report post-test measurements
  1.  ;; in section 5.
  1.  ;;
  1.  ;; a. ROM for lateral excursion
  1.  ;;    ___ Greater than 4 mm
  1.  ;;    ___ 0 to 4 mm
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;;    ___ No objective evidence of painful motion
  1.  ;;    ___ Greater than 4 mm
  1.  ;;    ___ 0 to 4 mm
  1.  ;;
  1.  ;; b. ROM for opening mouth, measured by inter-incisal distance
  1.  ;;    ___ Greater than 40 mm
  1.  ;;    ___ 31 to 40 mm
  1.  ;;    ___ 21 to 30 mm
  1.  ;;    ___ 11 to 20 mm
  1.  ;;    ___ 0 to 10 mm
  1.  ;;
  1.  ;; Select where objective evidence of painful motion begins:
  1.  ;;    ___ No objective evidence of painful motion
  1.  ;;    ___ Greater than 40 mm
  1.  ;;    ___ 31 to 40 mm
  1.  ;;    ___ 21 to 30 mm
  1.  ;;    ___ 11 to 20 mm
  1.  ;;    ___ 0 to 10 mm
  1.  ;;
  1.  ;; c. If ROM does not conform to the normal range of motion identified above but
  1.  ;; is normal for this Veteran (for reasons other than a temporomandibular joint
  1.  ;; condition, such as age, body habitus, neurologic disease), explain: _________
  1.  ;; _____________________________________________________________________________
  1.  ;;^TOF^
  1.  ;; 5. ROM measurement after repetitive use testing
  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. Post-test ROM for lateral excursion
  1.  ;;    ___ 0 to 4 mm
  1.  ;;    ___ Greater than 4 mm
  1.  ;;
  1.  ;; c. Post-test ROM for opening mouth, measured by Inter-incisal distance
  1.  ;;    ___ Greater than 40 mm
  1.  ;;    ___ 31 to 40 mm
  1.  ;;    ___ 21 to 30 mm
  1.  ;;    ___ 11 to 20 mm
  1.  ;;    ___ 0 to 10 mm
  1.  ;;
  1.  ;; 6. Functional loss and additional limitation in ROM
  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 defines
  1.  ;; functional loss as the inability to perform normal working movements of the
  1.  ;; body with normal excursion, strength, speed, coordination and/or endurance.
  1.  ;;
  1.  ;; a. Does the Veteran have additional limitation in ROM of either TMJ following
  1.  ;; repetitive-use testing?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; b. Does the Veteran have any functional loss or functional impairment of
  1.  ;; either TMJ?
  1.  ;; ___ Yes   ___ No
  1.  ;;
  1.  ;; c. If the Veteran has functional loss, functional impairment and/or additional
  1.  ;; limitation of ROM of either TMJ after repetitive use, indicate the contributing
  1.  ;; factors of disability below (check all that apply and indicate side affected):
  1.  ;;    ___ No functional loss for right TMJ
  1.  ;;    ___ No functional loss for left TMJ
  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 to
  1.  ;;        execute skilled movements smoothly   ___ Right  ___ Left  ___ Both
  1.  ;;    ___ Pain on movement                     ___ Right  ___ Left  ___ Both
  1.  ;;    ___ Swelling                             ___ Right  ___ Left  ___ Both
  1.  ;;    ___ Deformity                            ___ Right  ___ Left  ___ Both
  1.  ;;^TOF^
  1.  ;; 7. Pain (pain on palpation) and crepitus
  1.  ;; a. Does the Veteran have localized tenderness or pain on palpation of joints
  1.  ;; or soft tissues of either TMJ?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, side affected:     ___ Right  ___ Left  ___ Both
  1.  ;;
  1.  ;; b. Does the Veteran have clicking or crepitation of joints or soft tissues of
  1.  ;; either TMJ?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, side affected:     ___ Right  ___ Left  ___ Both
  1.  ;;
  1.  ;; 8. Other pertinent physical findings, complications, conditions, signs
  1.  ;; and/or symptoms
  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 area of
  1.  ;; 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, complications,
  1.  ;; conditions, signs and/or symptoms related to any conditions listed in the
  1.  ;; Diagnosis section above?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe (brief summary): ___________________________________________
  1.  ;;
  1.  ;; 9. Diagnostic testing
  1.  ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic arthritis
  1.  ;; must be confirmed by imaging studies. Once such arthritis has been documented,
  1.  ;; no further imaging studies are required by VA, even if arthritis has worsened. 
  1.  ;;
  1.  ;; a. Have imaging studies of the TMJ 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, side affected:     ___ Right  ___ Left  ___ Both
  1.  ;;
  1.  ;; b. Are there any other significant diagnostic test findings and/or results?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, side affected:     ___ Right  ___ Left  ___ Both
  1.  ;; If yes, provide type of test or procedure, date and results (brief summary):
  1.  ;; _____________________________________________________________________________
  1.  ;;^TOF^
  1.  ;; 10. Functional impact
  1.  ;; Does the Veteran's temporomandibular joint condition impact his or her ability
  1.  ;; to work?
  1.  ;; ___ Yes   ___ No
  1.  ;; If yes, describe the impact of each of the Veteran's temporomandibular
  1.  ;; conditions, providing one or more examples: _________________________________
  1.  ;; _____________________________________________________________________________
  1.  ;;
  1.  ;; 11. Remarks, if any:  _______________________________________________________
  1.  ;; _____________________________________________________________________________
  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 application.
  1.  ;;^END^
  1.  Q