DVBCQTJ2 ;;ALB-CIOFO/ECF - TEMPOROMANDIBULAR JOINT(TMJ) CONDITIONS QUESTIONNAIRE ; 9/JUNE/2011
;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
;
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 temporomandibular joint
;; condition?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to temporomandibular joint
;; conditions:
;;
;; Diagnosis #1: _________________________
;; ICD code: _____________________________
;; Date of diagnosis: ____________________
;;
;; Diagnosis #2: _________________________
;; ICD code: _____________________________
;; Date of diagnosis: ____________________
;;
;; Diagnosis #3: _________________________
;; ICD code: _____________________________
;; Date of diagnosis: ____________________
;;
;; If there are additional diagnoses that pertain to temporomandibular
;; joint conditions, list using above format.
;;
;; 2. Medical History
;; a. Describe the history (including onset and course) of the Veteran's
;; temporomandibular joint condition (brief summary): __________________________
;; _____________________________________________________________________________
;;
;; 3. Flare-ups
;; Does the Veteran report that flare-ups impact the function of the
;; temporomandibular joint?
;; ___ Yes ___ No
;; If yes, document the Veteran's description of the impact of flare-ups on
;;
;; function in his or her own words: ___________________________________________
;;^TOF^
;; 4. Initial range of motion (ROM) measurements
;; Measure ROM. 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. ROM for lateral excursion
;; ___ Greater than 4 mm
;; ___ 0 to 4 mm
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___ Greater than 4 mm
;; ___ 0 to 4 mm
;;
;; b. ROM for opening mouth, measured by inter-incisal distance
;; ___ Greater than 40 mm
;; ___ 31 to 40 mm
;; ___ 21 to 30 mm
;; ___ 11 to 20 mm
;; ___ 0 to 10 mm
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___ Greater than 40 mm
;; ___ 31 to 40 mm
;; ___ 21 to 30 mm
;; ___ 11 to 20 mm
;; ___ 0 to 10 mm
;;
;; c. If ROM does not conform to the normal range of motion identified above but
;; is normal for this Veteran (for reasons other than a temporomandibular joint
;; condition, such as age, body habitus, neurologic disease), explain: _________
;; _____________________________________________________________________________
;;^TOF^
;; 5. ROM measurement 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. Post-test ROM for lateral excursion
;; ___ 0 to 4 mm
;; ___ Greater than 4 mm
;;
;; c. Post-test ROM for opening mouth, measured by Inter-incisal distance
;; ___ Greater than 40 mm
;; ___ 31 to 40 mm
;; ___ 21 to 30 mm
;; ___ 11 to 20 mm
;; ___ 0 to 10 mm
;;
;; 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 either TMJ following
;; repetitive-use testing?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have any functional loss or functional impairment of
;; either TMJ?
;; ___ Yes ___ No
;;
;; c. If the Veteran has functional loss, functional impairment and/or additional
;; limitation of ROM of either TMJ after repetitive use, indicate the contributing
;; factors of disability below (check all that apply and indicate side affected):
;; ___ No functional loss for right TMJ
;; ___ No functional loss for left TMJ
;; ___ 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 to
;; execute skilled movements smoothly ___ Right ___ Left ___ Both
;; ___ Pain on movement ___ Right ___ Left ___ Both
;; ___ Swelling ___ Right ___ Left ___ Both
;; ___ Deformity ___ Right ___ Left ___ Both
;;^TOF^
;; 7. Pain (pain on palpation) and crepitus
;; a. Does the Veteran have localized tenderness or pain on palpation of joints
;; or soft tissues of either TMJ?
;; ___ Yes ___ No
;; If yes, side affected: ___ Right ___ Left ___ Both
;;
;; b. Does the Veteran have clicking or crepitation of joints or soft tissues of
;; either TMJ?
;; ___ Yes ___ No
;; If yes, side affected: ___ Right ___ Left ___ Both
;;
;; 8. 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): ___________________________________________
;;
;; 9. 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 TMJ been performed and are the results
;; available?
;; ___ Yes ___ No
;; If yes, is degenerative or traumatic arthritis documented?
;; ___ Yes ___ No
;; If yes, side affected: ___ Right ___ Left ___ Both
;;
;; b. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;; If yes, side affected: ___ Right ___ Left ___ Both
;; If yes, provide type of test or procedure, date and results (brief summary):
;; _____________________________________________________________________________
;;^TOF^
;; 10. Functional impact
;; Does the Veteran's temporomandibular joint condition impact his or her ability
;; to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's temporomandibular
;; conditions, providing one or more examples: _________________________________
;; _____________________________________________________________________________
;;
;; 11. 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[HDVBCQTJ2 9224 printed Apr 09, 2024@20:50:05 Page 2
DVBCQTJ2 ;;ALB-CIOFO/ECF - TEMPOROMANDIBULAR JOINT(TMJ) CONDITIONS QUESTIONNAIRE ; 9/JUNE/2011
+1 ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;;
+5 ;; 1. Diagnosis
+6 ;; Does the Veteran now have or has he/she ever had a temporomandibular joint
+7 ;; condition?
+8 ;; ___ Yes ___ No
+9 ;;
+10 ;; If yes, provide only diagnoses that pertain to temporomandibular joint
+11 ;; conditions:
+12 ;;
+13 ;; Diagnosis #1: _________________________
+14 ;; ICD code: _____________________________
+15 ;; Date of diagnosis: ____________________
+16 ;;
+17 ;; Diagnosis #2: _________________________
+18 ;; ICD code: _____________________________
+19 ;; Date of diagnosis: ____________________
+20 ;;
+21 ;; Diagnosis #3: _________________________
+22 ;; ICD code: _____________________________
+23 ;; Date of diagnosis: ____________________
+24 ;;
+25 ;; If there are additional diagnoses that pertain to temporomandibular
+26 ;; joint conditions, list using above format.
+27 ;;
+28 ;; 2. Medical History
+29 ;; a. Describe the history (including onset and course) of the Veteran's
+30 ;; temporomandibular joint condition (brief summary): __________________________
+31 ;; _____________________________________________________________________________
+32 ;;
+33 ;; 3. Flare-ups
+34 ;; Does the Veteran report that flare-ups impact the function of the
+35 ;; temporomandibular joint?
+36 ;; ___ Yes ___ No
+37 ;; If yes, document the Veteran's description of the impact of flare-ups on
+38 ;;
+39 ;; function in his or her own words: ___________________________________________
+40 ;;^TOF^
+41 ;; 4. Initial range of motion (ROM) measurements
+42 ;; Measure ROM. During the measurements, document the point at which painful
+43 ;; motion begins, evidenced by visible behavior such as facial expression,
+44 ;; wincing, etc. Report initial measurements below.
+45 ;;
+46 ;; Following the initial assessment of ROM, perform repetitive use testing. For
+47 ;; VA purposes, repetitive use testing must be included in all joint exams. The
+48 ;; VA has determined that 3 repetitions of ROM (at a minimum) can serve as a
+49 ;; representative test of the effect of repetitive use. After the initial
+50 ;; measurement, reassess ROM after 3 repetitions. Report post-test measurements
+51 ;; in section 5.
+52 ;;
+53 ;; a. ROM for lateral excursion
+54 ;; ___ Greater than 4 mm
+55 ;; ___ 0 to 4 mm
+56 ;;
+57 ;; Select where objective evidence of painful motion begins:
+58 ;; ___ No objective evidence of painful motion
+59 ;; ___ Greater than 4 mm
+60 ;; ___ 0 to 4 mm
+61 ;;
+62 ;; b. ROM for opening mouth, measured by inter-incisal distance
+63 ;; ___ Greater than 40 mm
+64 ;; ___ 31 to 40 mm
+65 ;; ___ 21 to 30 mm
+66 ;; ___ 11 to 20 mm
+67 ;; ___ 0 to 10 mm
+68 ;;
+69 ;; Select where objective evidence of painful motion begins:
+70 ;; ___ No objective evidence of painful motion
+71 ;; ___ Greater than 40 mm
+72 ;; ___ 31 to 40 mm
+73 ;; ___ 21 to 30 mm
+74 ;; ___ 11 to 20 mm
+75 ;; ___ 0 to 10 mm
+76 ;;
+77 ;; c. If ROM does not conform to the normal range of motion identified above but
+78 ;; is normal for this Veteran (for reasons other than a temporomandibular joint
+79 ;; condition, such as age, body habitus, neurologic disease), explain: _________
+80 ;; _____________________________________________________________________________
+81 ;;^TOF^
+82 ;; 5. ROM measurement after repetitive use testing
+83 ;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
+84 ;; ___ Yes ___ No If unable, provide reason: ___________________________
+85 ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
+86 ;; If Veteran is able to perform repetitive-use testing, measure and report ROM
+87 ;; after a minimum of 3 repetitions.
+88 ;;
+89 ;; b. Post-test ROM for lateral excursion
+90 ;; ___ 0 to 4 mm
+91 ;; ___ Greater than 4 mm
+92 ;;
+93 ;; c. Post-test ROM for opening mouth, measured by Inter-incisal distance
+94 ;; ___ Greater than 40 mm
+95 ;; ___ 31 to 40 mm
+96 ;; ___ 21 to 30 mm
+97 ;; ___ 11 to 20 mm
+98 ;; ___ 0 to 10 mm
+99 ;;
+100 ;; 6. Functional loss and additional limitation in ROM
+101 ;; The following section addresses reasons for functional loss, if present, and
+102 ;; additional loss of ROM after repetitive-use testing, if present. The VA defines
+103 ;; functional loss as the inability to perform normal working movements of the
+104 ;; body with normal excursion, strength, speed, coordination and/or endurance.
+105 ;;
+106 ;; a. Does the Veteran have additional limitation in ROM of either TMJ following
+107 ;; repetitive-use testing?
+108 ;; ___ Yes ___ No
+109 ;;
+110 ;; b. Does the Veteran have any functional loss or functional impairment of
+111 ;; either TMJ?
+112 ;; ___ Yes ___ No
+113 ;;
+114 ;; c. If the Veteran has functional loss, functional impairment and/or additional
+115 ;; limitation of ROM of either TMJ after repetitive use, indicate the contributing
+116 ;; factors of disability below (check all that apply and indicate side affected):
+117 ;; ___ No functional loss for right TMJ
+118 ;; ___ No functional loss for left TMJ
+119 ;; ___ Less movement than normal ___ Right ___ Left ___ Both
+120 ;; ___ More movement than normal ___ Right ___ Left ___ Both
+121 ;; ___ Weakened movement ___ Right ___ Left ___ Both
+122 ;; ___ Excess fatigability ___ Right ___ Left ___ Both
+123 ;; ___ Incoordination, impaired ability to
+124 ;; execute skilled movements smoothly ___ Right ___ Left ___ Both
+125 ;; ___ Pain on movement ___ Right ___ Left ___ Both
+126 ;; ___ Swelling ___ Right ___ Left ___ Both
+127 ;; ___ Deformity ___ Right ___ Left ___ Both
+128 ;;^TOF^
+129 ;; 7. Pain (pain on palpation) and crepitus
+130 ;; a. Does the Veteran have localized tenderness or pain on palpation of joints
+131 ;; or soft tissues of either TMJ?
+132 ;; ___ Yes ___ No
+133 ;; If yes, side affected: ___ Right ___ Left ___ Both
+134 ;;
+135 ;; b. Does the Veteran have clicking or crepitation of joints or soft tissues of
+136 ;; either TMJ?
+137 ;; ___ Yes ___ No
+138 ;; If yes, side affected: ___ Right ___ Left ___ Both
+139 ;;
+140 ;; 8. Other pertinent physical findings, complications, conditions, signs
+141 ;; and/or symptoms
+142 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+143 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+144 ;; section above?
+145 ;; ___ Yes ___ No
+146 ;; If yes, are any of the scars painful and/or unstable, or is the total area of
+147 ;; all related scars greater than 39 square cm (6 square inches)?
+148 ;; ___ Yes ___ No
+149 ;; If yes, also complete a Scars Questionnaire.
+150 ;;
+151 ;; b. Does the Veteran have any other pertinent physical findings, complications,
+152 ;; conditions, signs and/or symptoms related to any conditions listed in the
+153 ;; Diagnosis section above?
+154 ;; ___ Yes ___ No
+155 ;; If yes, describe (brief summary): ___________________________________________
+156 ;;
+157 ;; 9. Diagnostic testing
+158 ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic arthritis
+159 ;; must be confirmed by imaging studies. Once such arthritis has been documented,
+160 ;; no further imaging studies are required by VA, even if arthritis has worsened.
+161 ;;
+162 ;; a. Have imaging studies of the TMJ been performed and are the results
+163 ;; available?
+164 ;; ___ Yes ___ No
+165 ;; If yes, is degenerative or traumatic arthritis documented?
+166 ;; ___ Yes ___ No
+167 ;; If yes, side affected: ___ Right ___ Left ___ Both
+168 ;;
+169 ;; b. Are there any other significant diagnostic test findings and/or results?
+170 ;; ___ Yes ___ No
+171 ;; If yes, side affected: ___ Right ___ Left ___ Both
+172 ;; If yes, provide type of test or procedure, date and results (brief summary):
+173 ;; _____________________________________________________________________________
+174 ;;^TOF^
+175 ;; 10. Functional impact
+176 ;; Does the Veteran's temporomandibular joint condition impact his or her ability
+177 ;; to work?
+178 ;; ___ Yes ___ No
+179 ;; If yes, describe the impact of each of the Veteran's temporomandibular
+180 ;; conditions, providing one or more examples: _________________________________
+181 ;; _____________________________________________________________________________
+182 ;;
+183 ;; 11. Remarks, if any: _______________________________________________________
+184 ;; _____________________________________________________________________________
+185 ;;
+186 ;; Physician signature: _____________________________________ Date: ____________
+187 ;;
+188 ;; Physician printed name: __________________________________
+189 ;;
+190 ;; Medical license #: __________________
+191 ;;
+192 ;; Physician address: __________________________________________________________
+193 ;;
+194 ;; Phone: _______________________________ Fax: ________________________________
+195 ;;
+196 ;; NOTE: VA may request additional medical information, including additional
+197 ;; examinations if necessary to complete VA's review of the Veteran's application.
+198 ;;^END^
+199 QUIT
